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LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 


PRESENTED  BY 

DONALD  BEEKS 


MANUAL 


OF 


PSYCHIATRY 


BY 

J.  pOGUES  DE  FURSAC,  M.D. 

FORMERLY   CtllEF   OF   CLIXIC   AT   THE   MEDICAL,  FACULTV   OF   PARIS 

PHYSICIAN     IX     CHIEF     OF     THE     PUBLIC     INS-4JfE 

ASYLUMS  OF   THE   SEIXE    DEPARTMEXT 

AND 

A.  J.  ROSANOFF,  M.D. 

FIRST   ASSISTAXT   PHY'SICIAX,   KIXGS   PARK   STATE   HOSPITAL,   X.  Y. 


FOURTH  EDITION.     REVISED  AND  ENLARGED 


NEW  YORK 

JOHN  WILEY  &  SONS,  Inc. 

London:  CIL\PMAN  &  HALL,  Limtted 

1916 


Copyright,  1905, 1908, 1911, 1916, 

BT 

A.  J.  BOSANOFF. 


Stanbopc  iprcss 

.GILSON    COMPANY 
BOSTON,  U.S.A. 


PREFACE  TO  THE  FOURTH  EDITION. 


A  DEMAND  for  a  new  edition  came  again  as  an 
opportunity  of  bringing  this  Manual  up  to  date,  in 
viewpoint  as  well  as  in  subject  matter,  —  an  under- 
taking which  has  led  to  extensive  alterations,  re- 
arrangements, and  additions. 

In  the  first  part  of  the  book,  the  chapters  dealing 
with  etiology,  history  taking,  methods  of  examina- 
tion, special  diagnostic  procedures,  general  prognosis, 
prevalence  of  mental  disorders,  prevention,  and 
medico-legal  questions,  and,  in  the  second  part, 
those  deahng  with  Huntington's  chorea,  cerebral 
syphilis,  and  traumatic  psychoses  are  either  wholly 
new  or  almost  so. 

The  chapter  on  general  therapeutic  indications, 
in  the  first  part  of  the  book,  and  those  on  dementia 
prsecox,  chronic  alcoholism,  general  paresis,  and 
mental  disorders  due  to  organic  cerebral  affections, 
in  the  second  part,  have  been  more  or  less  exten- 
sively revised  or  added  to. 

The  remaining  chapters  have  also  been  carefully 
gone  over  and  corrected  or  altered  wherever  it 
seemed  necessary  or  advisable  to  do  so. 

Owing  to  the  war  in  Europe  a  close  cooperation 
between  the  French  and  the  American  collaborators 
has  been  impossible ;  it  was  therefore  agreed  between 


IV  PREFACE 

them  to  place  the  preparation  of  the  fourth  edition 
entirely  in  the  hands  of  the  American  collaborator; 
and  it  is  but  the  duty  of  the  latter  to  acknowledge 
his  full  responsibihty  for  the  above-mentioned  changes 
and  additions. 

The  favorable  reception  of  this  Manual  has  been 
most  gratifying  to  its  authors,  as  the  best  proof  of 
its  having  with  some  measure  of  success  filled  an 
existing  need;  their  earnest  hope  is  that  it  will  con- 
tinue to  do  so. 

A.    J.    ROSANOFF. 

Kings  Park,  Long  Island,  N.  Y., 
Apnl,  1916. 


COInTTENTS. 


Page 
Preface iii 

Introduction ix 

PART  I.  — GENERAL  PSYCHIATRY. 

I.  —  Etiology 1 

Essential  causes:  heredity,  alcoholism,  syphilis,  head 
injuries.  —  Incidental  or  contributing  causes.  —  Other 
etiological  factors:  race,  age,  sex,  environment,  occu- 
pation, marital  condition,  education,  immigration. 

II.  —  Symptomatology 21 

Disorders  of  perception:  insufficiency  of  perception, 
illusions,  hallucinations;  properties  common  to  all  hal- 
lucinations, the  different  varieties  of  hallucinations, 
theories  of  hallucinations. 

III.  —  Symptomatology  {continued) 47 

Consciousness,  memory,  attention,  association  of 
ideas,  judgment:  unconsciousnes.s,  clouding  of  con- 
sciousness, disorientation,  states  of  obscuration,  hyper- 
consciousness;  different  forms  of  amnesia,  illusions  and 
hallucinations  of  memory,  pseudo-reminiscences,  hyper- 
mnesia;  weakening  of  attention,  flight  of  ideas,  inco- 
herence, imperative  ideas,  fixed  ideas,  autochthonous 
ideas;  disorders  of  judgment,  delusions. 

IV.  —  Symptomatology  {concluded) 74 

Affectivity,  reactions,  personality:  morbid  indiffer- 
ence, exaggeration  of  affectivity,  morbid  depression, 
anger,  and  joy;  aboulia,  automatic  reactions,  suggesti- 
bility, impulsive  reactions,  stereotypy,  negativism;  dis- 
orders of  coenesthesia,  alterations  of  personality. 


VI  CONTENTS. 

Paqb 
V.  —  The  Practice  of  Psychiatry 94 

History  taking:  family  history,  personal  history,  his- 
tory of  psychosis.  —  Methods  of  examination:  physical 
examination,  mental  examination. 

VI.  —  The  Practice  of  Psychiatry  {continued) 109 

Special  diagnostic  procedures:  lumbar  puncture, 
Wassermann  reaction,  Lange's  colloidal  gold  test,  Nogu- 
chi's  butyric  acid  test,  Ross-Jones  ammonium  sulphate 
test,  Binet-Simon  tests,  examination  for  aphasia,  asso- 
ciation tests,  other  tests. 

VII.  —  The  Practice  of  Psychiatry  (continued) 159 

General  therapeutic  indications:  institution,  com- 
mitment, treatment  of  excitement,  suicidal  tendencies, 
refusal  of  food. —  Psychotherapy.  —  Parole  and  dis- 
charge. —  After-care. 

VIII.  —  The  Practice  of  Psychiatry  (concluded) 183 

Prognosis,  prevalence  of  mental  disorders,  preven- 
tion, medico-legal  questions. 


PART   II.  — SPECIAL   PSYCHIATRY. 

Classification 223 

I.  —  Arrests  of  Development 225 

Idiocy,  imbecility,  and  fecble-mindedncss. 

II.  —  Epilepsy 234 

III.  —  Dementia  Pr^i^^cox 246 

Symptoms  common  to  all  forms,  simple  form,  cata- 
tonia, delusional  forms,  delire  chroyiique  a  evolution 
systcmatique,  diagnosis,  prognosis,  etiology,  nature,  pa- 
thological anatomy,  and  treatment. 

IV.  —  Paranoia 287 


CONTENTS.  VU 

Page 

V.  —  Manic-Depressive  Psychoses 293 

Manic  types:  simple,  delusional,  confused  mania.  — 
Depressed  types:  simple,  delusional,  stuporous  depres- 
sion.—  Mixed  types:  mixed  type  proper,  attacks  of 
double  form.  —  Course,  prognosis,  diagnosis;  homoge- 
neity of  manic-depressive  insanity;  treatment.  — 
Chronic  mania. 

VI.  —  Involutional  Melancholia 324 

VII.  —  Hysteria.    Constitutional  Psychopaths.    Moral 

Insanity 334 

VIII.  —  Huntington's  Chorea 359 

IX.  —  Acute  Alcoholism.     Pathological  Drunkenness.    363 

X.  —  Chronic  Alcoholism 368 

Permanent  symptoms:  psychic,  physical.  —  Diag- 
nosis, prognosis,  pathological  anatomy,  etiology.  — 
Episodic  accidents:  delirium  tremens,  acute  hallucin- 
osis, delusional  states,  the  polyneuritic  psychosis 

XI.  —  Gentiral  Paresis 393 

Prodromal  period,  essential  symptoms,  inconstant 
symptoms,  forms,  course  and  prognosis,  diagnosis, 
pathological  anatomy,  etiology,  prevention,  treatment. 

XII.  —  Cerebral  Syphilis 437 

Diffuse  meningitic  type,  gummatous  type,  endarter- 
itic  type;   diagnosis,  prognosis,  treatment. 

XIII.  —  Cerebral  Arteriosclerosis 444 

Arterial  supply  of  the  brain,  systemic  sjonptoms, 
symptoms  common  to  all  forms,  symptoms  of  occlusion 
of  large  vessels,  disease  of  the  medullary  system  of 
terminal  arterioles,  disease  of  the  cortical  system  of 
terminal  arterioles;  diagnosis,  course,  prognosis,  treat- 
ment. 

XIV.  —  Traumatic  Psychoses 453 

Traumatic  delirium,  neurasthenia,  epilepsy,  demen- 
tia. 


VUl  CONTENTS. 

Page 

XV.  —  Miscellaneous  Groups 458 

Deliria  of  infectious  origin. 

XVI.  —  Miscellaneous  Groups  {continued) 462 

Psychoses  of  exhaustion:  primary  mental  confusion, 
acute  delirium. 

XVII.  —  Miscellaneous  Groups  (continued) 471 

Chronic  intoxication  by  the  alkaloids:    morphino- 
mania,  cocainomania. 

XVIII.  — Miscellaneous  Groups  {continued) 482 

Psychoses  of  auto-intoxication :  ura;mic  delirium. 

XIX.  —  Miscellaneous  Groups  {continued) 485 

Thyrogenic  psychoses:    myxcedema,  cretinism. 

XX.  —  Miscellaneous  Groups  {continued) 491 

Mental  disorders  due  to  organic  cerebral  affections: 
tumors,  multiple  sclerosis,  brain  abscess,  central  neuritis. 

XXI.  —  Miscellaneous  Groups  {concluded) 467 

Senile  dementia:  general  symptomatology,  delusional 
forms,  compUcationa,  prognosis,  diagnosis,  treatment. 


INTRODUCTION. 


Psychiatry  is  that  branch  of  neurology  which 
treats  of  mental  disorders  and  of  the  organic  changes 
associated  with  them. 

Mental  disorders  arrange  themselves  in  two  funda- 
mental categories,  characterized  respectively  by  in- 
sufficiency  and  perversion  of  the  intellectual  or  moral 
faculties. 

Insufficiency  may  be  either  congenital  or  acquired. 
In  the  first  case  it  constitutes  arrest  of  development; 
in  the  second,  psychic  paralysis.  When  the  psychic 
paralysis  is  temporary,  causing  a  suspension,  but  not 
a  destruction,  of  mental  activity,  the  name  psychic 
inhibition  is  applied  to  it;  on  the  other  hand,  when 
it  is  permanently  established,  it  constitutes  mental 
enfeeblement  or  dementia. 

Perversion  of  the  intellectual  and  moral  faculties 
may  also  be  congenital  or  acquired.  Various  terms 
are  applied  to  its  manifestations,  depending  upon 
the  particular  function  affected :  hallucinations,  de- 
lusions, morbid  impulses,  etc. 

Mental  diseases  or  psychoses  are  affections  in  which 
mental  sjTnptoms  constitute  a  prominent  feature. 
They  differ  from  such  mental  infirmities  as  idiocy, 
moral  insanity,  and  many  states  of  dementia,  in  that 
they  are  expressions  of  active  pathological  processes 


X  INTRODUCTION. 

and  not  of  permanent  and  fixed  alterations  of  the 
mind. 

Psychic  infirmity,  when  not  congenital,  occurs  as 
the  outcome  of  mental  disease.  The  relation  be- 
tween the  two  conditions  is  analogous  to  that  which 
exists  between  ankylosis  of  a  joint  and  the  arthritis 
which  produced  it ;  the  latter  is  a  disease,  the  former 
an  infirmity. 

Two  general  terms  still  remain  to  be  defined :  men- 
tal alienation  and  insanity.  Although  they  are  often 
employed  indiscriminately,  their  meaning  is  not 
quite  identical. 

Etymologically,  an  alienated  (Lat.  alienus)  indi- 
vidual is  one  who  has  become  ''estranged"  from  him- 
self, who  has  lost  the  control  of  his  mental  activity, 
who,  in  other  words,  is  not  responsible  for  his  acts. 
This  definition  rests  upon  the  metaphysical  con- 
ception of  a  free  will  and  cannot  find  a  place  in 
medical  science,  which  must  be  based  on  observation 
and  must  adhere  to  demonstrable  facts. 

It  is  better  to  adopt  an  essentially  practical  defi- 
nition, as  has  been  done  by  most  modern  psychia- 
trists, and  to  designate  by  the  term  mental  alienation 
the  entire  class  of  pathological  states  in  which  the 
mental  disorders,  whatever  their  nature  be  other- 
wise, present  an  anti-social  character.  Not  every 
individual  suffering  from  a  psychic  affection  is 
alienated.  This  term  can  be  applied  only  to  those 
who,  on  account  of  some  mental  disease  or  infirmity, 
are  likely  to  enter  into  conflict  with  society  and  to 
find  themselves,  in  consequence,  unable  to  be  an 
integral  part  of  it. 


INTRODUCTION.  XI 

Insanity,  as  a  scientific  term,  is  falling  into  disuse 
and  now  retains  a  significance  mainly  as  a  legal  one. 
Like  lunacy  it  seems  destined  to  become  obsolete. 
For  the  present  it  would  be  best  to  restrict  its  ap- 
plication to  cases  in  which  the  mental  disorder  is  of 
such  a  nature  as  to  render  advisable  commitment  for 
treatment  or  custody  to  a  special  institution.  Thus, 
according  to  the  law  of  the  state  of  New  York,  an 
imbecile,  an  epileptic,  or  a  senile  dement  (''dotard") 
is  not  insane  unless  he  presents,  in  addition  to  the 
underlying  infirmity,  such  manifestations  as  attacks 
of  excitement  or  depression,  hallucinations,  or  de- 
lusions; similarly,  some  cases  of  hysteria,  neu- 
rasthenia, cerebral  arteriosclerosis,  or  brain  tumor 
may  be  declared  ''insane"  and  committed  to  an  in- 
stitution, and  others  not,  depending  on  their  mani- 
festations. 

This  Manual  is  divided  into  two  parts.  The  first 
part  treats  of  general  psychiatry  and  comprises  a 
study  of  the  causes,  s;yTnptoms,  treatment  and  pre- 
vention of  mental  disorders,  considered  independ- 
ently of  the  affections  in  which  they  are  encountered. 
The  second  part  is  devoted  to  special  psychiatry, 
that  is  to  say,  to  the  study  of  individual  psychoses. 

It  has  been  thought  advisable  to  devote  a  good 
deal  of  space  to  general  psychiatry,  at  least  relatively 
to  the  size  of  the  whole  book.  A  precise  if  not  an 
extensive  knowledge  of  the  more  important  elemen- 
tary psychic  disorders  would  seem  to  be  altogether 
indispensable  for  an  understanding  of  the  genesis 
and  evolution  of  the  psychoses. 


MANUAL   OF  PSYCHIATRY. 


PART  I. 

GENERAL    PSYCHIATRY. 


CHAPTER  I. 

ETIOLOGY. 

"On  studying  closely  the  etiology  of  mental 
diseases  one  soon  recognizes  the  fact  that  in  the  great 
majority  of  cases  the  disease  is  produced  —  not  by 
a  particular  or  specific  cause,  but  by  a  series  of  un- 
favorable conditions  which  first  prepare  the  soil  and 
then,  by  their  simultaneous  action,  determine  the 
outbreak  of  insanity."^ 

This  was  written  nearly  three-quarters  of  a  cen- 
tury ago.  To-day,  though  this  view  is  still  held  to 
a  certain  extent,  we  are  nevertheless  able  to  dis- 
tinguish amongst  the  many  causes  some  few  that 
are  essential  from  others  that  are  merely  incidental 
or  contributing.  In  addition  there  are  other  factors 
that  have  to  do  with  the  etiology  of  mental  dis- 
orders, especially,  race,  age,  sex,  environment,  occu- 
pation, marital  condition,  education,  and  immi- 
gration. 

^  Griesinger.     Die  Pathologie  und  Therapie  der  GeisleskrankheUen. 

1 


2  MANUAL  OF  PSYCHIATRY. 

§  1.   Essential  Causes. 

As  implied  in  the  term  itself,  the  essential  causes 
are  those  in  the  absence  of  which  mental  disorders 
do  not  occur.  Of  these  by  far  the  most  important 
are  heredity,  alcoholism,  syphilis,  and  head  injuries. 

Each  of  these  alone  may  suffice  to  produce  a  mental 
disorder,  or  it  may  act  by  rendering  the  nervous 
organization  so  vulnerable  that  a  breakdown  occurs 
at  the  occasion  of  some  incidental  cause  which  may 
be  in  itself  quite  insignificant  but  which  here  comes 
to  play  the  part  of  "the  last  straw  that  broke  the 
camel's  back." 

Heredity.  —  By  heredity  is  understood  the  exist- 
ence in  ascendants  of  a  normal  or  pathological  peculi- 
arity which  is  transmitted  to  descendants.  Heredity 
is  direct  when  it  passes  from  parent  to  offspring;  at- 
avistic when  it  skips  one  or  more  generations;  col- 
lateral when  the  trait  under  consideration  is  found 
only  in  collateral  relatives  and  not  in  direct  ascend- 
ants. It  is  similar  when  the  anomaly  present  in  the 
descendant  is  the  same  as  that  in  the  ascendant;  in 
the  opposite  case  it  is  dissimilar.  The  latter  form  is 
by  no  means  uncommon :  among  the  ascendants  and 
collateral  relatives  of  the  so-called  insane  are  to  be 
found  instances  not  only  of  similar  psychoses,  but 
also  of  dissimilar  ones  and  of  epilepsy,  feeble- 
mindedness, criminality,  temperamental  abnormal- 
ities, sex  immorality,  and  other  neuropathic  mani- 
festations. 

The  fact  that  nervous  and  mental  diseases  are 
often  transmitted  by  heredity  was  known  to  Hippoc- 


ETIOLOGY.  3 

rates  and  has  since  his  time  been  amply  attested  by 
insane  hospital  statistics,  but  the  exact  conditions 
under  which  such  transmission  occurs  have  never 
been  fully  understood.  Especially  perplexing  has 
been  the  seeming  irregularity  in  the  working  of 
heredity  as  presented,  on  the  one  hand,  in  the  above- 
mentioned  facts  of  atavistic  and  collateral  heredity 
and,  on  the  other  hand,  in  the  frequent  failure  of 
transmission  of  neuropathic  traits.  Recent  investi- 
gations have,  however,  revealed  some  data  which 
seem  to  indicate  that  some  mental  disorders  are 
transmitted  from  parent  to  offspring  in  the  manner 
•of  a  trait  which  is,  in  the  Mendelian  sense,  recessive 
to  the  normal  condition.^ 

The  bearing  of  the  Mendelian  theory  seems  to  be 
of  such  importance  in  this  connection  that  a  brief 
statement  of  it  may  not  be  considered  out  of  place. 

The  total  inheritance  of  an  individual  is  divisible  into  unit  char- 
acters each  of  which  is  inherited  more  or  less  independently  of  all 
the  rest  and  may  therefore  be  studied  without  reference  to  other 
characters. 

The  inheritance  of  any  such  character  is  believed  to  be  dependent 
upon  the  presence  in  the  germ  plasm  of  a  unit  of  substance  called 
a  determiner. 

With  reference  to  any  given  character  the  condition  in  an  individ- 
ual may  be  dominant  or  recessive:  the  character  is  dominant  when, 
depending  on  "the  presence  of  its  determiner  in  the  germ  plasm,  it 
is  plainly  manifest;    and  it  is  recessive  when,  owing  to  the  lack  of 

^  H.  H.  Goddard.  Heredity  of  Feeble-Mindedness.  Bulletin 
No.  1,  Eugenics  Record  Office,  Cold  Spring  Harbor,  N.  Y.  —  A.  J. 
Rosanoff  and  Florence  I.  Orr.  A  Study  of  Heredity  in  Insanity  in 
the  Light  of  the  Mendelian  Theory.  Bulletin  No.  5.  —  C.  B.  Daven- 
port and  D.  F.  Weeks.  A  First  Study  of  Inheritance  in  Epilepsy. 
Bulletin  No.  4. 


4  MANUAL  OF  PSYCHIATRY. 

its  determiner  in  the  germ  plasm,  it  is  not  present  in  the  individual 
imder  consideration. 

The  dominant  and  recessive  conditions  of  a  character  are  often 
designated  by  the  symbols  D  and  R,  respectively. 

To  make  the  matter  clearer  we  may  take  as  an  example  of  a 
Mendelian  character  the  case  of  eye  color. 

The  brown  color  is  the  dominant  condition  while  the  blue  color 
is  the  recessive  condition,  as  has  been  shown  by  Davenport.'  It 
would  seem  that  the  inheritance  of  brown  eyes  is  due  to  the  presence 
in  the  germ  plasm  of  a  determiner  upon  which  the  formation  of 
brown  pigment  in  the  anterior  layers  of  the  irides  depends. 

On  the  other  hand,  the  inheritance  of  blue  eyes  is  believed  to  be 
due  to  the  lack  of  the  determiner  for  brown  eye  pigment  in  the 
germ  plasm;  for  the  blue  color  of  eyes  is  due  merely  to  the  absence 
of  brown  pigment,  the  effect  of  blue  being  produced  by  the  choroid 
coat  shining  through  the  opalescent  but  pigment-free  anterior 
layers  of  the  irides  in  such  cases. 

It  must  be  borne  ir  mind  that  as  regards  the  condition  of  any 
character  every  person  inherits  from  two  sources^  namely,  from  each 
parent.  Therefore,  with  reference  to  any  character  he  may  be  pure 
bred  or  hybrid. 

A  case  of  inheritance  of  a  character  from  both  parents  is  spoken 
of  as  one  of  duplex  inheritance  and  is  often  designated  by  the  symbol 
DD. 

A  case  of  inheritance  of  a  character  from  only  one  parent  is  spoken 
of  as  one  of  simplex  inheritance  and  is  designated  by  the  symbol  DR. 

A  case  in  which  a  character  is  not  inherited  from  either  parent, 
therefore  exhibiting  the  recessive  condition,  is  spoken  of  as  one  of 
nulliplex  inheritance  and  is  designated  by  the  symbol  RR. 

We  are  now  in  a  position  to  estimate  the  relative  number  of 
each  type  of  offspring  according  to  theoretical  expectation  in  the 
case  of  any  combination  of  mates. 

There  are  but  six  theoretically  possible  combinations  of  mates. 
Continuing  to  make  use  of  the  case  of  eye  color  as  an  instance  of  a 
Mendelian  character,  let  us  consider  in  turn  each  theoretical  possi- 
bility. 

1.  Both  i)arents  blue-cycMl  (nulliplex):  all  children  will  be  blue- 
eyed,  as  may  be  represented  by  the  following  biological  formula: 

RR  X  RR  =  RR. 

1  Science,  N.  S.,  Vol.,  XXVI,  Nov.  1,  1907,  pp.  589-592. 


ETIOLOGY.  5 

2.  One  parent  brown-eyed  and  simplex  (that  is  to  say,  inherit- 
ing the  determiner  for  brown  eye  pigment  from  one  grandparent 
only),  the  other  blue-eyed:  haK  the  children  will  be  brown-eyed 
and  simplex  and  the  other  half  blue-eyed: 

DR  X  RR  =  DR  +  RR. 

3.  One  parent  brown-eyed  and  duplex,  the  other  blue-eyed:  aU 
the  children  will  be  brown-eyed  and  simplex: 

DD  X  RR  ==  DR. 

4.  Both  parents  brown-eyed  and  simplex:  one-fourth  of  the 
children  will  be  brown-eyed  and  duplex,  one-half  will  be  brown- 
eyed  and  simplex,  and  the  remaining  one-fourth  wiU  be  blue-eyed 
(nuUiplex) : 

DR  X  DR  -=  DD  +  2DR  +  RR. 

5.  Both  parents  brown-eyed,  one  duplex  the  other  simplex:  all 
the  children  will  be  brown-eyed,  half  duplex  and  half  simplex: 

DD  X  DR  =  DD  +  DR. 

6.  Both  parents  brown-eyed  and  duplex:  all  the  children  will 
be  brown-eyed  and  duplex: 

DD  X  DD  =  DD. 

It  will  be  readily  seen  from  these  formula?  that  in  attempting  to 
predict  the  proportions  of  the  various  types  of  offspring  that  may 
result  from  a  given  mating  it  is  necessary  to  know,  not  only  whether 
the  character  is  in  each  parent  dominant  or  recessive,  but  in  the 
case  of  the  dominant  condition  also  whether  it  is  duplex  or  simplex. 

Turning  again  to  the  case  of  eye  color,  an  individual  with  blue 
ej'es  we  know  to  be  nulliplex  as  he  has  no  b^o^vn  pigment  in  his 
eyes  and  therefore  could  not  have  inherited  the  determiner  for 
bro\\-n  eye  pigment  from  either  parent.  But  how  are  we  to  judge 
in  the  case  of  a  brown-eyed  person  whether  he  has  inherited  the 
determiner  for  that  character  from  both  parents  or  only  from  one? 
We  can  judge  this  only  by  a  study  of  the  ancestry  and  offspring 
of  the  individual. 

To  put  the  whole  matter  in  a  nutshell,  the  essential  difference 
between  a  dominant  and  a  recessive  condition  of  a  character  is  in 
the  fact  that  in  a  case  of  simplex  inheritance  the  dominant  con- 
dition is  plainly  manifest  while  the  recessive  condition  is  not  ap- 
parent and  can  be  known  to  exist  only  through  a  study  of  ancestry 
and  offspring. 


6  MANUAL  OF  PSYCHIATRY. 

« 

This  is  important  because  it  constitutes  the  criterion  by  which 
we  are  able  to  determine  whether  any  given  inherited  peculiarity 
or  abnormality  is,  as  compared  with  the  average  or  normal  con- 
dition, dominant  or  recessive. 

According  to  the  assumption  that  most  of  the  in- 
heritable mental  disorders  are,  like  the  trait  of  blue 
eyes,  transmitted  in  the  manner  of  Mendelian  re- 
cessives,  theoretical  expectation  would  be  as  follows: 

1.  Both  parents  being  neuropathic,  all  children  will  be  neuro- 
pathic. 

2.  One  parent  being  normal,  but  with  the  neuropathic  taint 
from  one  grandparent,  and  the  other  parent  being  neuropathic, 
half  the  children  will  be  neuropathic  and  half  will  be  normal,  but 
capable  of  transmitting  the  neuropathic  make-up  to  their  progeny. 

3.  One  parent  being  normal  and  of  pure  normal  ancestry,  and 
the  other  parent  being  neuropathic,  all  the  children  will  be  normal 
but  capable  of  transmitting  the  neuropathic  make-up  to  their 
progeny. 

4.  Both  parents  being  normal,  but  each  with  the  neuropathic 
taint  from  one  grandparent,  one-fourth  of  the  children  will  be 
normal  and  not  capable  of  transmitting  the  jieuropathic  make-up 
to  their  progeny,  one-half  will  be  normal  but  capable  of  transmitting 
the  neuropathic  make-up,  and  the  remaining  one-fourth  will  be 
neuropathic. 

5.  Both  parents  being  normal,  one  of  pure  normal  ancestry  and 
the  other  with  the  neuropathic  taint  from  one  grandparent,  all  the 
children  will  be  normal;  half  of  them  will  be  capable  and  half  not 
capable  of  transmitting  the  neuropathic  make-up  to  their  progeny. 

6.  Both  parents  being  normal  and  of  pure  normal  ancestry,  all 
the  children  will  be  normal  and  not  capable  of  transmitting  the 
neuropathic  make-up  to  their  progeny. 

Table  1  (from  Rosanoff  and  Orr,  loc.  cit.)  gives 
actual  findings  alongside  of  theoretical  expectation, 
and  it  will  be  seen  that  the  correspondence  between 
the  two  sets  of  figures  is  very  close. 


ETIOLOGY. 


TABLE   1. 


Types  of  Mating. 


L  RRXRR  =RR 

2.  DRXRR  =DR+RR 

3.  DDXRR=DR 

4.  DRXDR=DD+2DR+RR 

5.  DDXDR  =  DD+DR 

6.  DDXDD  =  DD 

Totals 


206 


-so 


75 
500 

61 
369 

92 
0 


1097 


11 
66 
13 
44 
12 
0 


146 


I  Neuro- 
pathic 

Off- 
spring. 


c 

to     o  .2 


54 

190 

0 

107 

0 

0 


351 


''^ 


64 

214^ 

0 

80^ 
0 
0 


Normal 

Off- 
spring. 


"& 


10 
239 

45 
215 

77 
0 


359  ;586 


0 

214J 

45 

241i 

77 
0 

578 


The  more  important  mental  disorders  which  are 
supposed  to  develop  on  a  hereditary  basis  are: 
arrests  of  development,  epileptic  psychoses,  con- 
stitutional psychopathic  states,  dementia  prsecox, 
paranoia,  manic-depressive  psychoses,  involutional 
melancholia,  and  allied  conditions.  Of  7664  cases 
admitted  to  the  New  York  state  hospitals  during 
the  year  ending  September  30,  1913,  3326,  or  43.4 
%,  belonged  to  these  groups.^ 

Alcoholism.  —  The  most  trustworthy  experimental 
data  that  are  available,  among  which  may  be  men- 
tioned those  of  Schneider,^  Hellsten,^  Mayer,"^  Aschaf- 

*  Twenty-fifth  Annual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1914. 

2  Pflueger's  Archiv  f.  d.  gesamte  Physiologic,  Vol.  XCIII,  p.  451. 
'  Abstracted  in  ]\Iuenchener  medicinische  Wochenschrift,   1904, 
p.  1894. 

*  M.  Mayer.  Ueber  die  Beeinfiussung  der  Schrift  durch  den 
Alkohol.     Kraepelin's  Psychol.  Arb.,  Vol.  Ill,  p.  535. 


8  MANUAL  OF  PSYCHIATRY. 

fenburg,^  Smith, ^  Kiirz  and  Kraepelin,^  seem  to  show 
that  even  moderate  indulgence  in  alcohol,  though 
producing  in  the  subject  a  sense  of  well-being  and  of 
increased  physical  and  mental  ability,  in  reality 
causes  impairment  of  muscular  power  and  coordi- 
nation and  of  mental  efficiency. 

Excessive  indulgence  produces  the  sufficiently 
familiar  picture  of  drunkenness,  and  such  excesses, 
if  frequently  repeated,  are  apt  sooner  or  later  to 
produce  one  or  another  of  the  alcoholic  psychoses, 
of  which  the  more  important  are:  delirium  tremens, 
acute  hallucinosis,  a  fairly  characteristic  chronic 
delusional  state,  the  polyneuritic  psychosis,  and 
alcoholic  dementia.  During  the  year  ending  Sep- 
tember 30,  1913,  13.5%  of  all  male  admissions  and 
4.2%  of  all  female  admissions  to  the  New  York  state 
hospitals  were  cases  of  alcoholic  psychoses.^  This 
does  not  include  cases  which  were  not  specifically 
alcoholic  but  in  which  intemperance  was  given  as  a 
contributing  cause. 

Syphilis.  —  Syphilis  appears  as  the  essential  cause 
of  all  cases  of  general  paresis  and  of  cerebral  syphilis 
(gummata,  meningitides,  etc.),  and  of  a  large  pro- 
portion of  the  cases  of  cerebral  arteriosclerosis.     Not 

^  G.  Aschaffonburg.  Prakiischc  AHmt  unter  Alkoholwirkung. 
Kraopelin'n  P.sychol.  Arb.,  Vol.  I,  p.  008. 

^  A.  Sinitli.  IJchcr  die  Becinjlussung  cinjacher  psjjchischer  Vor- 
gdiKjr  (lurch  chronurhe  Alkoholvcrgiflung.  Br.  ueber  d.  V.  intern. 
Kongr.  z.  Bokfimpf.  d.  Missbr.  goist.  Gctriinke,  Basel,  1896,  p.  341. 

'  Kiirz  and  Kracpelin.  Uehcr  die  Becinjlussung  psychischer 
Vorgdinje  dnrch  rcgdmdssigcn  Alkoholismus.  Kraepelin'a  Psychol. 
Arb.,  Vol.  Ill,  p.  417. 

*  Twenty-fifth  Ainiual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1914. 


ETIOLOGY.  9 

counting  cases  of  the  latter  condition,  which  are  not 
always  of  syphilitic  origin,  19.4%  of  all  male  first  ad- 
missions and  7.0%  of  all  female  first  admissions  to  the 
New  York  state  hospitals  during  the  year  ending 
September  30,  1913,  occurred  on  the  basis  of  syphilis 
as  an  essential  cause. ^ 

Head  Injuries.  —  The  more  important  mental  dis- 
orders occurring  as  result  of  head  injuries  are:  trau- 
matic delirium,  traumatic  neurasthenia,  traumatic 
epilepsy,  and  traumatic  dementia.  These  cases  are 
far  more  often  brought  to  general  hospitals  than  to 
hospitals  for  the  insane  for  reasons  that  are  suf- 
ficiently obvious.  Thus  only  0.6%  of  all  first  ad- 
missions to  the  New  York  state  hospitals  during  the 
year  ending  September  30,  1913,  were  cases  of 
traumatic  psychoses.^ 

§  2.   Incidental  or  Contributing  Causes. 

The  incidental  or  contributing  causes  are  remark- 
able for  their  multiplicity  and  complexity;  one 
might  almost  say  that  they  are  as  many  as  there  are 
individual  cases  and  that  in  no  two  cases  is  their 
manner  of  action  exactly  alike.  In  themselves,  how- 
ever, they  do  not  suffice  to  produce  insanity,  but 
acquire  pathogenicity  only  in  the  presence  of  an 
essential  cause. 

Some  are  met  with  in  practice  with  special  fre- 
quency and  therefore  seem  to  possess  quasi-specific 
potency  in  the  production  of  mental  disorders. 

Alcoholism,  which  has  been  already  mentioned  as 

1  Twenty-fifth  Annual  Report  of  the  State  Hospital  Commission, 
Albany,  N.  Y.,  1914. 


10  MANUAL  OF  PSYCHIATRY. 

an  essential  cause,  may  also  act  as  a  contributing 
cause  in  the  presence  of  a  predisposition  created  by 
one  of  the  other  essential  causes.  Thus,  acting  on  a 
basis  of  bad  heredity,  alcoholism  may  determine  the 
development  of  dementia  pra3cox  or  of  a  manic-de- 
pressive or  an  epileptic  attack ;  and  some  hold  that  a 
syphilitic  subject  who  is  also  intemperate  is  more 
likely  to  develop  general  paresis  than  one  who  is 
abstinent.  Thus,  of  the  15.2%  of  first  admissions  to 
the  New  York  state  hospitals  during  the  year  ending 
September  30,  1913,  which  were  attributed  to  alco- 
holism, only  9.4%  were  cases  of  specifically  alcoholic 
psychoses,  the  remaining  5.8%  being  cases  in  which 
alcoholism  played  the  part  merely  of  a  contributing 
cause. 

Head  injuries,  like  alcoholism,  are  probably  capable 
of  acting  not  only  as  essential  but  also  as  contribut- 
ing causes,  especially  as  factors  in  the  etiology  of 
general  parefeis;  their  importance  in  this  connection 
will  be  again  discussed  in  the  chapter  devoted  to  this 
psychosis. 

For  the  rest,  recent  studies  seem  to  indicate  that 
the  incidental  or  contributing  causes  that  are  met 
with  are  -psychic  rather  than  physical  in  their  nature 
or  manner  of  operation.^ 

Even  such  causes  as  pregnancy,  abortion,  childbirth, 

'  Adolf  Meyer.  The  Role  of  the  Menial  Factors  in  Psychiatry. 
N.  Y.  State  Hosp.  Bulletin,  N.  S.,  Vol.  I,  1908,  p.  262. —  Jung. 
The  Psychology  of  Dementia  Proicox.  English  translation  by 
Peterson  and  Brill,  New  York,  1909.  —  A.  J.  Rosanoff.  Exciting 
Causes  in  Psychiatry.  Amer.  Journ.  of  Insanity,  Vol.  LXIX,  1912, 
p.  351.  —  August  Hoch.  Precipitating  Mental  Causes  in  Dementia 
Proecox,     Amer.  Journ.  of  Insanity,  Vol.  LXX,  1914,  p.  637. 


ETIOLOGY.  11 

and  lactation  are  found  in  the  better  analyzed  cases  to 
act  not  as  physical  causes  but  through  psychic  ac- 
companiments, such  as  illegitimacy,  increasingly 
hopeless  domestic  infelicity,  apprehension  of  added 
hardships;  although  it  is  undoubtedly  also  true  that 
such  conditions  as  febrile  or  exhaustion  deliria  may 
be  produced  by  these  causes  acting  in  a  physical  way, 
especially  in  the  presence  of  complications  like  ex- 
cessive hemorrhage  or  infection. 

Among  the  plainly  psychic  causes  may  be  men- 
tioned the  following  as  being  the  more  common: 
Business  troubles:  financial  difficulties  loss  of  em- 
ployment, inability  to  get  employment,  failure  in 
school  examinations.  Domestic  troubles:  abuse  by 
husband,  infidelity  of  husband,  intemperance  of 
husband,  desertion,  other  conditions  of  marital  in- 
felicity. Love  affairs:  disappointment  in  love,  unre- 
quited love.     Death  or  illness  of  relatives. 

Perhaps  in  half  the  cases  represented  in  state 
hospital  statistics  no  exciting  cause  is  given.  In 
some  of  these  cases  this  is  due  merely  to  the  histories 
being  incomplete,  and  in  these  the  fact  that  no 
causes  were  assigned  does  not  prove  that  none  were 
to  be  found;  but  in  most  cases  the  ordinary  data  are 
on  record  and  the  fact  is  that  neither  the  patients  nor 
their  relatives  were  able  to  discern  in  the  conditions 
of  existence  anything  that  could  be  regarded  as  a 
pathogenic  influence.  Yet  it  is  not  probable  that  the 
mechanisms  of  the  development  of  the  psychoses  in 
these  cases  differs  essentially  from  that  of  the  cases 
with  a  definitely  assigned  cause.  When  some  strik- 
ing occurrence  in  the  environment  of  a  patient  is 


12  MANUAL  OF  PSYCHIATRY. 

followed  by  a  mental  upset  it  is  not  apt  to  be  over- 
looked by  relatives  or  friends,  but  is  rather  likely  to 
be  mentioned  as  a  cause  even  when  an  etiological  re- 
lationship is  not  readily  to  be  established.  On  the 
other  hand,  when  an  unfavorable  environment  in- 
sidiously undermines  a  subject's  power  of  adjust- 
ment and  thus  gradually,  without  sudden  catastrophe, 
leads  to  the  development  of  a  psychosis  its  signifi- 
cance is  seldom  fully  appreciated,  so  that  in  histories 
furnished  by  lay  informants,  as  they  generally  are, 
no  cause  is  assigned. 

§  3.   Other  Etiological  Factors. 

Race.  —  An  excellent  opportunity  of  investigating 
the  influence  of  race  on  the  occurrence  of  mental  dis- 
orders is  afforded  by  the  experience  of  the  hospitals 
for  the  insane  serving  the  city  of  New  York,  where 
people  of  various  races  are  living  under  approxi- 
mately similar  conditions.  This  opportunity  has 
been  well  utilized  in  a  study  by  Kirby.^  Table  2, 
compiled  from  the  figures  furnished  in  that  study, 
shows  the  relative  frequency  of  certain  psychoses  in 
people  of  different  races,  given  in  figures  representing 
percentages  of  the  total  number  of  admissions  for 
each  race  to  the  Manhattan  State  Hospital,  on 
Ward's  Island,  during  the  year  ending  September  30, 
1908.  It  will  be  observed  that  the  Irish  are  most 
liable  to  alcoholic  psychoses,  while  the  Jews  are 
practically  free  from  them;  the  latter,  on  the  other 
hand,  suffer  most  from  the  constitutional  psychoses. 


1  Geo.    H.    Kirby.     A    Study  in   Race   Psychopathology.     N.   Y. 
State  Hosp.  Bulletin,  N.  S.,  Vol.  I,  1909,  p.  663. 


ETIOLOGY. 


13 


especially  dementia  prsecox  and  manic-depressive 
psychoses.  The  negroes  are  most  liable  to  general 
paresis, 

TABLE  2. 


Psychoses. 


Senile  psychoses 

General  paresis 

Alcoholic  psychoses 

Dementia  prajcox 

Manic-depressive  psychoses 

Epileptic  psychoses 

Other  psychoses 

Total  number  of  each  race . 


% 

9.80 

7.59 
27.69 
13.48 
16.66 

2.20 
22.58 


408 


% 

2.87 
14.05 

0.32 
27.47 
28.43 

1.59 
25.27 


313 


O 


6.70 
20.10 
11.85 
14.95 
12.89 

4.64 
28.87 


194 


/o 

7.14 
17.46 
11.90 
16.66 
18.25 

3.17 
25.42 


126 


% 

3.70 

9.87 

8.64 

23.44 

13.58 

4.93 

35.84 


81 


% 

9.80 
29.41 

7.82 
13.72 

9.80 

3.92 
25.53 


51 


General  paresis  is  said  to  be  rare  in  Arabs  and 
African  negroes,  although  syphilis  is  common.  This, 
however,  is  hardly  more  than  a  mere  impression, 
satisfactory  statistical  data  pertaining  to  this  subject 
being  as  yet  not  available. 

Age.  —  All  ages  do  not  equally  predispose  to  men- 
tal disorders.  In  general  it  appears  that  the  inci- 
dence of  the  psychoses,  as  indicated  by  state  hospital 
admissions,  increases  sharply  with  advancing  age. 
This  is  shown  in  Table  3,  which  is  based  on  statistics 
of  population  given  in  the  Thirteenth  Census  of  the 
United  States  and  on  those  of  hospital  admissions 
furnished  by  the  New  York  State  Hospital  Com- 
mission.^ 

The  ages  of  greatest  susceptibility  are  not  the  same 

1  Twenty-third  Aimual  Report,  Albany,  N.  Y.,'  1912. 


14 


MANUAL  OF  PSYCHIATRY. 


for  all  psychoses.  Senile  dementia  seldom  if  ever 
occurs  before  the  age  of  60.  Similarly,  involutional 
melancholia  is  rarely  seen  before  the  age  of  40. 
More  than  half  of  all  cases  of  general  paresis  are  seen 
between  the  ages  of  35  and  50.  The  onset  of  more 
than  half  of  all  cases  of  dementia  praecox  and  manic- 
depressive  psychoses  is  before  the  age  of  30.  More 
detailed  considerations  of  age  are  given  in  the 
chapters  devoted  to  the  various  psychoses. 

TABLE  3. 


Age  Groups. 


Under  15  years .  . 
15  to  19  "  .  .  , 
20  to  24  "  .  . 
25  to  29  "  .  . 
30  to  34  "  .  . 
35  to  39  "  .  . 
40  to  44  "  .  . 
45  to  49  "  .  . 
50  to  54  "  .  . 
55  to  59  "  .  . 
60  to  64  "  .  . 
65  years  and  over 
All  ages* 


Population, 
1910. 


2,459,923 
831,884 
920,433 
857,801 
•  750,725 
696,837 
589,428 
495,849 
412,759 
290,795 
235,307 
414,336 

8,966,842 


First  Ad- 
missions to 

the  State 
Hospitals. 


14 

282 
607 
675 
647 
625 
599 
497 
444 
322 
251 
666 
5660 


Admissions 
per  100,000 
of  Popu- 
lation. 


0.6 

33.9 

65.9 

78.7 

86.2 

89.7 

101.6 

100.2 

107.6 

110.7 

106.7 

160.7 

63.1 


Including  those  of  unknown  age. 


Sex.  —  Mental  disorders  are  more  frequent  in  the 
male  than  in  the  female  sex.  Thus  an  enumeration 
of  patients  in  institutions  for  the  insane  made  on 
January  1,  1910,  showed  for  the  entire  United  States 
an  average  of  208.5  men  and  only  199.6  women  per 
100,000  of  the  general  population.     An  even  greater 


ETIOLOGY.  15 

contrast  was  presented  by  the  admissions  to  the  in- 
stitutions during  the  year  1910,  which  were  72.1 
men  and  59.7  women  per  100,000  of  the  general 
population.  This  difference  seems  to  be  due  en- 
tirely to  the  greater  frequency  of  general  paresis 
and  of  alcoholic  psychoses  among  men,  the  admis- 
sions for  all  psychoses  other  than  these  being  about 
the  same  for  the  two  sexes,  averaging  54.4  men  and 
55.6  women  per  100,000  of  the  general  population.^ 

Environment.  —  Statistics  show  almost  invariably 
that  urban  populations  contribute  relatively  much 
greater  numbers  of  admissions  to  institutions  for 
the  insane  than  do  rural  ones.  Thus  during  the 
year  1910  the  urban  population  ^  of  the  United 
States  contributed  102.8  admissions,  and  the  rural 
population  but  41.4  per  100,000.^  This  difference 
can  be  partly  accounted  for  by  the  greater  prevalence 
of  alcoholism  and  syphilis  in  urban  populations. 
Another  factor  having  a  bearing  here  is  the  difference 
between  the  two  portions  of  the  population  in  age 
distribution:  only  27.2%  of  the  urban  population 
and  as  many  as  36.3%  of  the  rural  population  were 
under  15  years  of  age;  we  have  already  shown  that 
the  population  groups  under  15  years  of  age  contrib- 
ute but  a  very  minute  proportion  of  admissions  to 
institutions  for  the  insane. 

For  the  rest,  it  seems  probable  that  the  difference 

1  Insane  and  Feeble-Minded  in  Institutions.  Bureau  of  the 
Census,  Washington,  1914. 

2  The  expression  "urban  population"  is  here  used,  as  in  the 
U.  S.  Census,  to  designate  all  that  part  of  the  population  which 
resides  in  cities,  towns,  or  other  incorporated  places  of  2500  inhabit- 
ants or  more. 


16  MANUAL  OF  PSYCHIATRY. 

between  urban  and  rural  populations,  as  shown  in 
statistics,  is  due  not  to  a  corresponding  difference  in 
incidence  of  mental  disorders  but  to  purely  extrane- 
ous conditions,  especially  accessibility  of  institu- 
tions.^ 

Occupation.  —  It  is  hardly  to  be  doubted  that  oc- 
cupation has  an  influence  on  the  incidence  of  mental 
disorders,  although  satisfactory  statistics  pertaining 
to  this  matter  are  not  available.  Bartenders,  brew- 
ery and  distillery  employees,  and  hotel  waiters  are 
more  liable  than  most  others  to  alcoholic  psychoses; 
soldiers,  sailors,  traveling  salesmen,  and  railroad  em- 
ployees are  more  liable  to  general  paresis.  Phy- 
sicians, engineers,  architects,  clergymen,  and  lawyers 
would  probably  show  a  relatively  low  incidence  of 
the  graver  constitutional  psychoses. 

Marital  condition.  —  Of  all  patients  admitted  to 
the  institutions  for  the  insane  in  the  United  States 
during  the  year  1910,  48.4%  among  men  and  33.4% 
among  women  were  single.  In  the  adult  population 
at  large  only  38.7%  of  the  men  and  29.7%  of  the 
women  were  single,  —  this  in  spite  of  the  fact  that 
the  average  age  of  patients  admitted  is  higher  than 
that  of  the  general  adult  population  (over  15  years 
of  age)  and  that,  on  that  score,  the  percentage  of 
single  persons  should  be  less  and  not  greater  among 
the  hospital  admissions.  This,  however,  '4s  not  to 
be  interpreted  as  indicating  that  the  single  are  more 
liable  to  become  insane  than  the  married.     It  means 


1  A.  J.   Rosanoff.     A  Study  of  Eugenic  Forces.    Amer.  Joum. 
of  Insanity,  Vol.  LXXII,  1915. 


ETIOLOGY. 


17 


rather  that  the  insane  as  compared  with  the  normal 
are  less  likely  to  marry."  ^ 

An  interesting  relationship  is  also  to  be  observed 
between  certain  psychoses  and  the  state  of  widow- 
hood, divorces  and  separations.  Table  4,  copied 
from  statistics  furnished  by  the  New  York  State 
Hospital  Commission, 2  shows  that  the  percentages  of 
the  widowed,  divorced,  and  separated  were  highest 
in  the  general  paresis  and  alcoholic  groups ;  the  table 
also  shows  that  the  groups  of  constitutional  psy- 
choses have  the  highest  percentages  of  single  persons. 

TABLE  4. 


Per  cent  of  Total  of  Each  Psj-chosis 

Psychoses. 

Single. 

Widowed. 

Divorced 
and 

Separated. 

Males. 

Fem. 

Males. 

Fem. 

Males. 

Fem. 

General  paresis 

26.0 
39.5 
81.4 
60.1 

14.8 
11.9 
58.0 
41.3 

5.5 
9.8 
2.0 
4.5 

21.3 

23.1 

6.6 

9.2 

6.7 
6.6 
2.2 
2.1 

5.5 

Alcoholic  psychoses 

Dementia  prsecox 

Manic-depr.  psj-choses. . . 

9.7 
3.3 
3.1 

Education.  —  That  the  factor  of  education  is  in 
some  manner  related  to  the  incidence  of  mental  dis- 
orders is  uniformly  indicated  by  statistics  represent- 
ing the  experience  of  ever}!-  state  in  the  country. 


^  Insane    and    Feeble-Minded    in    Institutions.     Bureau    of    the 
Census,  Washington,  1914. 

2  Twenty-fifth  Annual  Report,  Albany,  N.  Y.,  1914. 


18  MANUAL  OF  PSYCHIATRY. 

Thus  on  January  1,  1910,  there  were  881.8  persons  in 
institutions  for  the  insane  per  100,000  of  the  white 
ilUterate  population  10  years  of  age  or  over  in  the 
United  States  and  only  225.8  per  100,000  of  the  liter- 
ate population.  The  constitutional  psychoses,  far 
more  than  others,  contribute  to  this  showing. 

The  conclusion  could  hardly  be  drawn  from  this 
that  illiteracy  is  to  any  great  extent  a  cause  of 
mental  disease,  rather  the  reverse  being  true  for  the 
most  part:  the  clinical  histories  of  the  illiterate  in- 
sane show  that  most  of  them  had  been  unable  to 
learn  to  read  and  write  owing  to  inherent  mental 
defectiveness. 

Immigration.  —  Immigration  in  relation  to  insanity 
presents  in  this  country  a  problem  of  great  magni- 
tude. Of  all  the  insane  in  institutions  in  the  United 
States  according  to  the  enumeration  of  the  Thir- 
teenth Census  29.3%  were  foreign  born;  of  the 
native  insane  30.7%  were  of  foreign  or  mixed  parent- 
age. The  figures  given  for  the  state  of  New  York 
are  even  more  striking :  41.4%  were  foreign  born;  of 
the  native  insane  51.0%  were  of  foreign  or  mixed 
parentage. 

Furthermore  it  has  been  shown  that  during  the 
year  ending  September  30,  1911,  the  native  popula- 
tion of  the  state  of  New  York  furnished  46.4  first  ad- 
missions per  100,000  to  the  state  hospitals,  while  the 
foreign  born  population  furnished  100.3  —  relatively 
2.19  times  as  many.^ 

1  H.  M.  Pollock.  A  Statistical  Study  of  the  Foreign-Born  Insane 
in  the  N.  Y.  State  Hospitals.  N.  Y.  State  Hoep.  Bulletin,  April, 
1912. 


ETIOLOGY.  19 

This  raises  the  important  question  whether  the  in- 
cidence of  insanity  is  really  greater  among  the  immi- 
grant races  than  in  the  older  white  population  in  this 
country  or  whether  some  other  conditions  are  re- 
sponsible for  this  showing. 

A  study  of  the  available  statistics  has  shown  that 
the  difference  in  age  distribution  which  exists  be- 
tween the  native  and  foreign-born  parts  of  the 
population  accounts  largely,  but  not  wholly,  for 
the  difference  in  the  proportion  of  insane  hospital 
admissions. 

The  difference  is  further,  but  still  not  wholly, 
accounted  for  by  the  greater  proportion  of  town 
dwellers  among  the  foreign-born  than  among  the 
native  population. 

Upon  eliminating  the  errors  resulting  from  these 
disturbing  factors  there  remains  but  a  slight  differ- 
ence between  the  native  and  foreign-born  parts  of 
the  population  in  the  incidence  of  certified  insanity. 

It  is  thought  that  this  remaining  slight  difference 
may  be  accounted  for  by  the  heavy  stress  entailed  in 
the  migration  and  in  the  subsequent  process  of  ad- 
justment to  new  conditions  and  more  exacting 
standards  of  living,  and,  possibly,  by  other,  less 
obvious,  disturbing  factors. 

Incidentally,  it  was  shown  that  the  migration  of 
native  American  masses  of  population  from  the  east- 
ern to  the  western  coast  has  produced  a  similar  effect 
in  creating  a  seeming  increase  in  the  incidence  of 
certified  insanity;  natives  of  the  state  of  New  York 
who  have  emigrated  to  California  have  contributed 
proportionately  2.60  times  as  many  admissions  to  the 


20  MANUAL  OF  PSYCHIATRY. 

state  hospitals  there  as  the  native  Cahfornians,  a 
showing  even  more  unfavorable  than  that  made  by 
the  foreign-born  population  in  the  state  of  New  York. 

Owing  to  the  practical  impossibility  of  eliminating 
all  sources  of  error  in  a  direct  comparison  of  the  in- 
sanity rates  in  the  native  and  foreign-born  parts  of 
the  population,  an  attempt  was  made  to  make  the 
comparison  by  an  indirect  method. 

Insanity  being,  in  large  measure  transmissible  by 
heredity,  any  real  difference  in  its  incidence  which 
may  exist  between  the  native  and  foreign-born  parts 
of  the  population  should  be  as  patent  in  the  offspring 
as  in  the  parents;  in  other  words,  it  should  be  as 
evident  between  native  persons  of  native  par- 
entage and  native  persons  of  foreign  parentage 
as  it  is  between  the  native  and  foreign-born  them- 
selves. 

Calculation  shows  that  in  the  state  of  New  York 
in  the  fiscal  year  ending  September  30,  1911,  the 
native  of  native  parentage  contributed  34.6  first 
admissions  to  the  state  hospitals  per  100,000  of 
their  general  population,  while  the  native  of 
foreign  parentage  contributed  34.9  —  practically 
the  same  proportion.^ 

The  conclusion  may,  therefore,  be  drawn  that 
there  is  no  evidence  to  show  that  there  is  a  greater 
proneness  toward  mental  disease  in  the  foreign-born 
than  in  the  native  population  and  that  the  excessive 
projiortion  of  hospital  admissions  furnished  ])y  the 
foreign-}:)orn  is  due  to  other  causes. 

^  A.  J.  Rosanoff.  Some  Neglected  Phases  of  Immigration  in 
Relation  to  Insanity.     Amcr.  Journ.  of  Insanity,  Vol.  LXXII,  1915. 


CHAPTER  II. 
SYMPTOMATOLOGY.  —  DISORDERS    OF    PERCEPTION. 

INSUFFICIENCY  OF  PERCEPTION.  — ILLUSION  S.- 
HALL UCINA  TIONS. 

"The  senses,"  says  Jean  Muller,  "inform  us  of  the 
various  conditions  of  our  body  by  the  special  sensa- 
tions transmitted  through  the  sensory  nerves.  They 
also  enable  us  to  recognize  the  quaUties  and  the  changes 
of  the  bodies  which  surround  us,  in  so  far  as  these 
determine  the  particular  state  of  the  nerves."^  The 
senses,  in  other  words,  are  the  means  through  which  we 
obtain  the  knowledge  of  our  own  bodies  and  of  the 
external  world. 

For  the  exercise  of  their  function  are  necessary :  (1)  the 
reception  of  an  internal  or  an  external  impression  by  a 
peripheral  organ;  (2)  the  transmission  of  this  impres- 
sion to  the  brain;  (3)  its  elaboration  by  the  cortical 
cells,  which  transform  it  into  a  phenomenon  of  con- 
sciousness: first  sensation  and  then  perception.  Only 
the  latter  operation  is  of  interest  to  the  alienist. 

We  shall  study  successively: 

I.  Insufficiency  of  perception; 

II.  Illusions  (inaccurate  perceptions); 

III.  Hallucinations  (imaginary  perceptions).    Halluci- 

*  Jean  Midler.     Manuel  de  Physiologie. 
21 


22  MANUAL  OF  PSYCHIATRY. 

nations  and  illusions  are  often  classed  together  under 
the  name  of  psychosensory  disorders. 

§  1.  Insufficiency  of  Perception. 

Insufficiency  of  perception  in  its  slightest  degree  may 
be  met  with  in  states  of  depression,  at  the  onset  of  con- 
fusional  states,  etc.  All  external  impressions  are  vague, 
uncertain,  and  strange.  The  patients  complain  that 
everything  has  changed  in  them  and  around  them: 
objects  and  persons  have  no  more  their  usual  aspect; 
the  sound  of  their  own  voice  startles  them. 

In  a  more  marked  degree  of  insufficiency  external 
impressions  no  longer  convey  to  the  mind  of  the  sub- 
ject any  clear  or  precise  idea;  questions  are  either  not 
understood  at  all,  or  understood  only  when  they  are 
very  simple,  brief,  energetically  put,  and  repeated 
several  times.  External  stimulation,  even  the  strong- 
est, is  but  vaguely  perceived  and  often  causes  no  re- 
action proportionate  to  its  intensity  or  appropriate  to 
its  nature. 

Finally,  complete  paralysis  of  one  or  several  forms 
of  psychosensory  activity  is  observed  either  in  con- 
nection with  profound  disorders  of  consciousness,  as  in 
confusional  insanity  of  the  stuporous  form,  or  by 
itself,  as  in  hysterical  amaurosis  or  deafness. 

Insufficiency  of  pcrc'(>i)tion  constitutes  an  important 
element  of  clouding  of  the  consciousness,  which  will 
be  considered  later  on. 

Its  pathogenesis  is  closely  connected  with  disorders 
of  ideation.  The  normal  act  of  perception  really  con- 
sists of  two  elements:    (1)  a  sensory  impression;    (2)  a 


SYMPTOMATOLOGY.  23 

series  of  associations  of  ideas  which  enables  the  mind 
to  recognize  the  impression  and  which  almost  always 
completes  it  and  renders  it  more  definite.  If  the 
associations  of  ideas  are  not  formed  in  sufficient  numbers 
the  perception  can  only  be  vague  and  ill  defined. 


§  2.   Illusions  (Inaccurate  Perceptions). 

An  illusion  may  be  defined  as  a  perception  which 
alters  the  quahties  of  the  object  perceived  and  pre- 
sents it  to  the  consciousness  in  a  form  other  than  its 
real  one.  An  individual  who  hears  insulting  words  in 
the  singing  of  birds  or  in  the  noise  of  carriage-wheels 
experiences  an  illusion. 

Illusions  are  of  frequent  occurrence  in  normal  indi- 
viduals. There  is  no  one  to  whom  the  folds  of  a  cur- 
tain seen  in  semi-darkness  have  not  appeared  to  assume 
more  or  less  fantastic  shapes.  But  the  mind,  aided  by 
the  testimony  of  the  other  senses,  recognizes  the  abnor- 
mal character  of  the  image;  the  illusion  is  recognized 
as  such.  By  the  insane  it  is  on  the  contrary  taken 
as  an  exact  perception  and  exercises  a  more  or  less 
marked  influence  upon  all  the  intellectual  functions. 

Illusions  affect  all  the  senses  and  present,  in  the 
case  of  each,  features  analogous  to  those  of  hallucina- 
tions; I  shall  therefore  not  describe  them  here.  I 
shall  say  but  a  few  words  concerning  illusions  of  sight 
which  present  certain  peculiarities. 

Illusions  of  sight  may  occur  in  most  of  the  psychoses, 
but  are  chiefly  found  in  the  toxic  psychoses  and  in  the 
infectious  deliria.    When  these  illusions  are  pertaining 


24  MANUAL  OF  PSYCHIATRY. 

to  persons  they  lead  to  mistakes  of  identity.  Many 
insane  persons  mistake  their  fellow  patients  or  employees 
of  the  institution  for  their  relatives  or  friends.  This 
form  of  illusion  sometimes  attains  such  completeness 
that  the  subject  may,  while  at  a  hospital,  believe  him- 
self to  be  at  his  home. 

Illusions  are  very  apt  to  occur  in  the  midst  of  vague 
impressions:  those  of  hearing  in  the  presence  of  con- 
fusing noises,  and  those  of  sight  in  semi-darkness. 

Like  incomplete  perceptions,  inaccurate  perceptions 
or  illusions  are  the  consequence  of  a  disorder  of  idea- 
tion; abnormal  associations  replace  normal  ones,  which 
are  absent,  and  complete  the  image,  altering  it  at  the 
same  time. 

§  3.  Hallucinations  (Imaginary  Perceptions). 

"A  person  who  has  an  inmost  conviction  of  a  sensa- 
tion actually  perceived,  when  no  external  object  capable 
of  exciting  such  sensation  is  within  reach  of  the  senses, 
is  in  a  state  of  hallucination"   (Esquirol). 

"By  hallucinations  are  understood  subjective  sensory 
images  which  arc  projected  outwardly  and  which  in 
that  way  acquire  objectivity  and  reality"  (Griesinger), 

"A  hallucination  is  a  perception  without  an  object" 
(Ball). 

These  three  definitions  are  essentially  identical.  That 
of  Ball  appears  to  me  to  be  the  best  on  account  of  its 
conciseness. 

Hallucinations  may  affect  any  of  the  senses.  There 
are  then^forc  as  many  varieties  of  hallucinations  as 
there  are  senses. 


SYMPTOMATOLOGY.  25 

Some  properties  are  common  to  all  varieties  of  hal- 
lucinations, others  are  peculiar  to  certain  varieties. 

A.    PROPERTIES     COMMON   TO    ALL    VARIETIES    OF 
HALLUCINATIONS. 

Hallucinations  exercise  an  influence  upon  the  psychic 
personality  of  the  patient,  which  varies  with  the  sub- 
ject, the  nature  of  the  disease,  and  the  different  stages 
of  the  same  disease. 

In  a  general  way  it  may  be  stated  that  the  more 
acute  the  character  of  the  mental  disorder  (acute 
psychoses,  periods  of  exacerbation  in  chronic  psychoses) 
and  the  less  enfeebled  the  intellectual  activity,  the 
more  marked  is  the  influence  of  the  hallucinations. 
In  accordance  with  this  rule,  the  correctness  of  which 
is  clinically  demonstrated,  hallucinations  abate  in 
their  influence  as  the  acute  stage  of  the  psychosis 
subsides  —  either  when  the  patient  enters  upon  conva- 
lescence, or  when  he  lapses  into  dementia;  under  such 
conditions  they  may  persist  for  a  greater  or  lesser 
length  of  time  without  exercising  any  influence  upon 
the  patient's  emotions  or  actions. 

The  influence  of  hallucinations  upon  the  psychic  func- 
tions.— Attention. — Hallucinations  force  themselves  upon 
the  attention  of  the  patient.  In  the  case  of  hallucina- 
tions of  hearing,  for  instance,  he  is  compelled  to  listen 
to  them,  sometimes  in  spite  of  himself,  no  matter  what 
their  degree  of  clearness  is, — whether  they  consist  of 
distinctly  spoken  words  or  phrases,  or  of  a  scarcely 
perceptible  murmur. 

The  patient  is  sometimes  conscious  of  the  tyrannical 
dominating  power  to  which  he  is  subjected.    "I  am 


26  MANUAL  OF  PSYCHIATRY. 

forced  to  listen  to  them/'  said  one  of  these  unfortu- 
nates; "when  they  (his  persecutors)  get  at  me  I  can 
do  no  work,  cannot  follow  any  conversation,  /  am 
wholly  in  their  power. '^  Hallucinations  thus  resemble 
imperative  ideas  and  autochthonous  ideas  which  we 
shall  study  later  on. 

Judgment. — Hallucinations  may  coexist  with  sound 
judgment  and  be  recognized  by  the  patient  as  a  patho- 
logical phenomenon.  They  are  then  called  conscious 
hallucinations.  Such  instances  are  not  very  rare  and 
consist  chiefly  of  hallucinations  of  sight.  A  celebrated 
case  is  that  of  Nicolai,  the  bookseller.  "The  visions 
began  in  1791,  after  an  omission  of  a  bloodletting  and 
an  application  of  leeches  which  he  underwent  habitually 
for  hemorrhoids.  All  of  a  sudden,  following  a  strong 
emotion,  he  saw  before  him  the  form  of  a  dead  person, 
and  on  the  same  day  diverse  other  figures  passed 
before  his  eyes.  This  repeated  itself  on  numerous 
occasions. 

"The  visions  were  involuntary  and  he  was  unable 
to  form  an  image  of  any  person  at  will.  Most  of 
the  time,  also,  the  phantoms  were  those  of  persons 
unknown  to  him.  They  appeared  during  the  day  as 
well  as  during  the  night,  assuming  the  colors  of  the 
natural  objects,  though  they  were  somewhat  paler. 
After  a  few  days  they  began  also  to  speak.  One 
month  after  the  onset  of  this  afi'ection,  leeches  Avere 
applied;  on  the  same  day  the  figures  became  more 
hazy  and  less  mobile.  They  disappeared  finally  after 
Nicolai  had  for  some  time  seen  only  certain  portions 
of  some  of  them."  i 

'  Jean  MuUer.     Loc  cit. 


SYMPTOMATOLOGY.  27 

Some  individuals  possess  the  power  of  producing 
hallucinations  at  will.  Goethe  had  that  power.  "As 
I  shut  my  eyes,"  he  said,  "and  lower  my  head  I  figure 
to  myself  a  flower  in  the  center  of  my  visual  organ; 
this  flower  does  not  retain  for  an  instant  its  original 
form;  it  forthwith  rearranges  itself  and  from  its  inte- 
rior appear  other  flowers  with  multicolored  or  some- 
times green  petals;  they  are  not  natural  flowers,  but 
fantastic,  though  regular,  figures  like  the  rosettes  of 
the  sculptors.  It  is  impossible  for  me  to  fix  the  creation, 
but  it  lasts  as  long  as  I  desire  without  increasing  or  di- 
minishing.'^ ^ 

In  the  great  majority  of  cases  the  judgment,  itself  dis- 
ordered, is  unable  to  correct  the  psychosensory  error: 
the  hallucination  is  taken  for  a  true  perception.  Though 
sometimes  in  the  beginning  of  the  disease  the  subject 
experiences  some  doubts,  this  transitory  incertitude 
is  soon  replaced  by  a  blind  belief  in  the  imaginary 
perception.  ''We  observe,"  says  Wernicke,  "that  the 
reality  of  a  hallucination  is  maintained  against  the 
testimony  of  all  the  other  senses,  and  that  the  patient 
resorts  to  the  most  fantastic  explanations,  rather 
than  admit  any  doubt  as  to  the  reality  of  his 
perception."  ^  An  individual,  alone  in  the  open  field, 
hears  a  voice  calling  him  a  thief.  He  will  invent  the 
most  absurd  hypotheses  rather  than  believe  himself  a 
victim  of  a  pathological  disorder. 

Certain  patients,  chiefly  the  weak-minded  and  the 
demented,  accept  their  hallucinations  without  inquiring 


'  Jean  MuUer.     Loc  cit. 

^  Wernicke.     Griindriss  der  Psychiatrie,  p.   126. 


28  MANUAL  OF  PSYCHIATRY. 

as  to  their  origin  or  mechanism;  others  on  the  con- 
trary strive  to  give  explanations  which  vary  with  the 
nature  of  the  malady,  the  degree  of  the  patient's  educa- 
tion and  intelligence,  and  the  current  ideas  of  the  times. 
In  the  middle  ages  psychosensory  disorders  were  often 
attributed  to  diabolic  intervention,  and  this  not  only 
by  patients  but  also  by  their  friends.  Patients  of  our 
own  times  mostly  resort  for  explanations  to  the  great 
modern  inventions  (electric  currents,  telephone.  X-rays, 
wireless  telegraphy,  etc.).  Some  fancy  to  themselves 
apparatus  or  imaginary  forces.  One  patient  attributed 
his  disturbances  of  general  sensibility  to  a  ''magneto- 
electro-psychologic"  current.  Another  received  the  vi- 
sions from  a  "theologico-celestial  projector." 

Ajfedivity. — Hallucinations  are  sometimes  agreeable, 
at  other  times  painful,  and  occasionally,  chiefly  in 
dements,  indifferent. 

In  the  first  case  their  outward  manifestations  are  an 
appearance  of  satisfaction,  an  expression  of  happiness, 
and  sometimes  ecstatic  attitudes. 

In  the  second  case,  which  is  the  most  frequent,  the 
patients  become  sad,  gloomy,  or,  on  the  contrary, 
agitated  and  violent,  a  prey  to  anxiety  or  anger. 

The  two  kinds  of  hallucinations,  agreeable  and  pain- 
ful, are  occasionally  encountered  in  the  same  subject. 
Sometimes  they  follow  each  other  without  any  regular 
order  and  are  coupled  with  a  variable  disposition  and 
incoherent  delusions,  as  in  maniacs  and  in  general 
paretics;  at  other  times  they  follow  each  other  some- 
what systematically — the  painful  hallucinations  are 
combated    by    the    agreeable     ones.       The    patients 


SYMPTOMATOLOGY.  29 

often  speak  of  their  persecutors,  who  insult,  threaten, 
and  abuse  them,  and  of  their  defenders  who  con- 
sole them,  reassure  them,  and  repair  the  damage 
done  by  the  former.  A  persecuted  patient  heard  a 
voice  call  her  "a  slut";  immediately  another  voice 
responded,  ''He  lies;  she  is  a  brave  woman."  Some 
patients  tell  of  their  limbs  being  smashed  and  their 
viscera  extracted  every  night,  but  that  nevertheless" 
they  are  sound  and  safe  when  they  arise,  thanks  to  the 
good  offices  of  their  defenders,  who  properly  replace 
everything.  These  two  sets  of  hallucinations  con- 
stitute what  the  patients  sometimes  call  the  attack  and 
the  defense. 

The  indifferent  hallucinations  are  of  but  little  inter- 
est. They  are  met  with  at  the  terminal  periods  of  pro- 
cesses of  deterioration,  and  also  at  the  beginning  of 
convalescence  in  acute  psychoses.  In  the  latter  case 
they  rapidly  become  conscious  hallucinations  and  finally 
disappear. 

Reactions. — ^The  influence  of  hallucinations  upon  the 
will  depends  upon  the  state  of  the  judgment  and  of  the 
affectivity.  If  the  judgment  is  sound,  if  the  hallucina- 
tions are  looked  upon  as  pathological  phenomena,  they 
give  rise  to  no  reaction;  and  the  same  is  the  case  when 
they  make  no  impression  upon  the  emotions. 

But  when  they  are  accepted  by  the  patient  as  real 
perceptions  and  influence  strongly  the  emotional  state, 
hallucinations,  on  the  contrary,  govern  the  will  to  a 
very  considerable  extent  and  prompt  the  patient  to 
defend  himself  against  the  ill-treatment  of  which  he 
believes  himself  to  be  the  object  or  to  obey  the  com- 
mands which  are  given  him  (imperative  hallucinations). 


30  MANUAL  OF   PSYCHIATRY. 

Hence  the  frequency  of  violent  and  criminal  acts  com- 
mitted by  the  insane,  and  the  well-known  axiom  in 
psychiatry  according  to  which  all  subjects  of  hallucina- 
tions are  dangerous  patients.  Revington  has  found, 
from  a  study  of  forty-nine  cases  of  homicide  committed 
by  insane  patients,  that  in  most  instances  the  murder 
resulted  from  a  hallucination.^ 

The  reactions  caused  by  hallucinations  are  often 
abrupt,  unreasonable,  and  of  an  impulsive  character, 
especially  in  the  feeble-minded  and  in  patients  with 
profound  clouding  of  consciousness  (delirium  tremens, 
epileptic  delirium).  But  they  may  also  show  all 
the  evidences  of  careful  premeditation.  Certain 
persecuted  patients,  exasperated  by  their  painful .  hal- 
lucinations, prepare  their  vengeance  with  infinite 
precaution. 

The  influence  of  hallucinations  upon  the  will  is  often 
so  powerful  that  nothing  can  combat  it,  neither  the 
sense  of  duty,  nor  the  love  of  family,  nor  even  the 
instinct  of  self-preservation.  A  patient  passing  near  a 
river  heard  a  voice  tell  him:  "Throw  yourself  into  the 
water."  He  obeyed  without  hesitation,  and  to  justify 
himself  declared  simply:  "They  told  me  to  do  it;  I 
was  forced  to  obey." 

Combined  hallucinations.  —  Sometimes  hallucinations 
affect  but  one  sense.  Such  are  the  hallucinations  of 
hearing  at  the  beginning  of  systematized  delusional 
states.  Generally,  however,  the  pathological  disorder 
affects  several  senses,  the  different  hallucinations  either 

'  Revington.  Menial  Conditions  Resulting  in  Homicide.  The 
Joum.  of  Ment.  Sc,  April,  1902. 


SYMPTOMATOLOGY.  31 

following  one  another,  or  existing  together  without  any 
correlation,  or  combining  themselves  and  producing 
complex  scenes  either  of  a  fantastic  aspect  or  analogous 
to  real  Mfe.  In  the  latter  case  they  bear  the  name  of 
combined  hallucinations.  The  patient  sees  imaginary 
persons,  hears  them  speak,  feels  the  blows  that  they 
inflict  upon  him,  makes  efforts  to  reject  the  poisonous 
substances  which  they  force  into  his  mouth,  etc.  This 
state,  closely  related  to  dreams,  is  always  accompanied 
with  marked  clouding  of  the  intellect. 

Diagnosis  of  hallucinations. — Two  possibilities  may 
present  themselves:  (1)  the  patient  directly  informs 
the  physician  about  his  condition;  (2)  he  gives  no 
information  whatever,  either  because  of  his  reticence  or 
because  of  his  intellectual  obtuseness. 

In  the  first  case  the  diagnosis  of  hallucinations  is  gen- 
erally easy.  It  is  necessary,  however,  to  ascertain  that 
the  pathological  phenomenon  is  really  a  hallucination, 
and  not  an  illusion;  in  other  words,  that  it  is  a  percep- 
tion without  an  object,  and  not  an  inaccurate  percep- 
tion. Only  a  detailed  examination  of  the  circumstances 
under  which  the  phenomenon  shows  itself  may  prevent 
an  error;  it  is  very  difficult  indeed  when  a  subject  hears 
himself  being  called  a  thief  in  the  midst  of  thousands  of 
street  noises,  to  decide  whether  he  experiences  a  hallu- 
cination or  an  illusion.  The  certainty  is,  on  the  other 
hand,  much  greater  when  the  morbid  perception  occurs 
in  absolute  silence,  as  during  the  night,  for  instance. 

In  the  second  case  the  diagnosis  must  be  made  with- 
out the  assistance  of  the  patient,  or  even  in  spite  of  his 
denials.  It  must  be  based  only  upon  the  patient's  atti- 
tudes, movements,   and  at  times  upon  the  means  of 


32  MANUAL  OF  PSYCHIATRY. 

defense  to  which  he  resorts  and  which  vary  according  to 
the  sense  affected.  The  ear  turned  for  some  time  in  a 
certain  direction,  the  eyes  fixed  or  following  a  definite 
Une  without  there  being  any  real  object  to  attract  them, 
the  ears  stuffed  with  foreign  bodies,  evidences  of  strong 
emotions,  an  expression  of  fear,  etc.,  lead  to  the  pre- 
sumption of  the  existence  of  hallucinations.  I  say  pre- 
sumption because  the  external  signs  do  not  enable  us  to 
establish  with  certainty  the  patient's  state  of  conscious- 
ness. Over-refined  psychological  analyses  are  to  be 
mistrusted  if  one  is  to  avoid  unwarranted  conclusions 
which  would  render  the  diagnosis  and  prognosis  faulty. 

Relations  between  hallucinations  and  other  mental 
disorders.  —  What  position  do  hallucinations  occupy  in 
the  genesis  of  the  psychoses?  Are  they  primary  or 
secondary? 

It  is  not  impossible  that  at  times,  notably  in  the 
intoxications  and  in  cases  of  localized  lesion,  hallucina- 
tions appear  first  and  are  the  cause  of  the  other  mental 
disturbances  which  follow.  In  practice,  however,  such 
cases  occur  but  rarely.  A  careful  and  complete  history 
almost  always  shows  that  the  hallucinations  are  pre- 
ceded by  other  symptoms:  depression,  intellectual 
obtuseness,  clouding  of  consciousness,  delusions,  etc. 

Indeed  it  is  difficult  to  conceive  of  one  or  more  hal- 
lucinations appearing  in  an  individual  free  from  all 
other  mental  trouble,  without  their  being  at  once  cor- 
rected by  the  judgment  aided  by  the  other  senses.  On 
the  other  hand  it  is  quite  intelligible  that  imaginary  per- 
ceptions may  exercise  an  influence  upon  the  attention, 
the  emotions,  the  judgment,  and  the  will,  if  they  are 
but  the  reflection   or  the   realization  of  the  patient's 


SYMPTOMATOLOGY.  33 

pre-occupations  and  morbid  ideas,  that  is  to  say,  if  they 
are  secondary.  The  melanchohac  who  beheves  himself 
guilty  of  a  crime  sees  and  hears  the  police  officers  who 
are  coming  to  arrest  him.  The  persecuted  patient  who 
beheves  himself  to  be  exposed  to  the  malevolence  of 
his  imaginary  enemies  hears  their  voices  insulting  him. 
The  general  paretic  mth  pleasing  and  expansive  delu- 
sions experiences  pleasant  sensations.  Hallucinations 
are,  then,  the  expression,  and  not  the  cause,  of  delusions; 
and  that  is  why  they  harmonize  so  perfectly  with  the 
mental  state  of  the  subject. 

Some  alienists  ^  have  described  a  hallucinatory  de- 
lirium as  a  distinct  morbid  entity  the  essential  features 
of  which  are  the  multiplicity  and  the  primary  character 
of  the  hallucinations.  If  the  idea  which  I  attempted 
to  expose  above  is  correct,  hallucinations,  never  or 
almost  never  being  primary,  cannot  form  the  essential 
and  exclusive  feature  of  an  affection,  and  hallucina- 
tory delirium  cannot  retain  its  autonomy.  For  this 
reason  most  authors  classify  such  cases  with  confusional 
insanity,  general  paresis,  dementia  praecox,  and  the 
toxic  psychoses. 

General  etiology  of  hallucinations.  —  On  this  subject 
we  possess  but  very  incomplete  information. 

Hallucinations  aj^pear  readily  in  states  of  impaired 
consciousness,  as  epilejitic  dchrium  and  the  toxic  psy- 
choses. The  hallucinations  which  precede  sleep  in 
certain  nervous  subjects  are  most  frequently  of  the  con- 
scious type  and  are  to  be  attributed  to  weakening  of 
consciousness. 

'  Farnarier.     La  psychose  hnlhicinatoire,  Paris,  1899. 


34  MANUAL  OF   PSYCHIATRY. 

Hallucinations  are  very  apt  to  appear  in  the  absence 
of  real  sensations,  —  those  of  hearing  during  silence  and 
those  of  vision  in  darkness.  This  explains  why  isolation 
in  prison-cells,  practiced  in  penitentiaries,  predisposes 
to  hallucinatory  psychoses  (Kirn,  Riidin).i 

In  some  instances  hallucinations  are  produced  in  a 
somewhat  automatic  manner,  at  the  occasion  of  some 
definite  impression.  One  patient  felt  a  taste  of  sulphur 
in  his  mouth  whenever  the  name  of  one  of  his  per- 
secutors was  uttered  in  his  presence.  Such  hallucina- 
tions have  been  described  by  Kahlbaum  under  the  name 
of  reflex  hallucinations. 

Hallucinations  may  depend  to  a  certain  extent  upon 
a  peripheral  excitation  either  of  the  sensory  organ 
itself  or  of  the  conducting  nerve.  They  are  in  such 
cases  frequently  unilateral.  "  Max  Busch  has  brought 
about  a  notable  improvement  in  the  mental  condition 
of  a  patient  who  had  auditory  hallucinations  which  were 
most  marked  on  the  left  side,  by  treating  his  otitis 
media  with  perforation  of  the  drum  membrane,  which 
he  had  contracted  during  childhood."  ^  Visual  hallu- 
cinations have  been  observed  to  appear  as  the  result 
of  ocular  lesions,  such  as  cataract,  and  to  disappear 
under  appropriate  treatment.  These  peripheral  lesions 
are,  so  to  speak,  but  a  pretext  for  the  hallucinations, 
and  are  not  to  be  considered  as  their  true  cause.  The 
cause  is  to  be  looked  for  in  the  special  state  of  morbid 
irritability  of  the  centers  of  [)ercfeption  which  causes 

'  Riidin.  Eine  Form  akulen  Jiallucinatorischen  Vcrfolgungswahns 
in  der  Ilnft,  etc.     Allf,'.  Zcitschr.  f.  Psychiat.,  1903. 

^  Quoted  by  IvOgiiy.  I'Jsfiai  S2ir  les  rapports  de  I'organe  aiuiitif 
avec  les  hallucinations  de  I'oule.     These  dc  Paris,  1898,  p.  25. 


SYMPTOMATOLOGY.  35 

them  to  react  by  hallucinatory  phenomena  to  abnormal 
peripheral  excitation.  ^  Hallucinations  sometimes  occur 
in  cases  in  which  the  corresponding  sensory  function  has 
been  lost  completely.  Thus  auditory  hallucinations  may 
be  associated  with  total  deafness,  unilateral  or  bilateral. 

Peripheral  hallucinations  are  very  analogous  to  Liep- 
mann's  phenomenon:  if  in  a  convalescing  alcoholic 
slight  pressure  is  made  upon  the  eyeballs,  hallucina- 
tions are  sometimes  induced,  even  when  the  subject 
does  not  any  more  experience  them  spontaneously. 
The  peripheral  excitation  transmits  to  the  brain 
nothing  but  a  nervous  discharge  the  clinical  expression 
of  which  is  the  hallucination.  The  fact  that  a  great 
many  patients  present  very  grave  and  old  standing 
lesions  of  the  sensory  organs  without  having  any  hallu- 
cinations is  also  evidence  to  prove  that  these  affections 
are  of  but  secondary  importance  in  the  causation  of 
psychosensory  disorders. 

Finally,  hallucinations  may  be  induced  by  sugges- 
tion. Sometimes  it  suffices  merely  to  fix  the  attention 
of  the  patient  upon  a  certain  point  for  him  to  dis- 
cover imaginary  objects,  persons,  or  forms.  Such  is  fre- 
quently the  case  in  toxic  states,  notably  alcoholism  and 
cocainomania,  also  in  certain  dementias.  In  an  obser- 
vation kindly  communicated  to  me  by  Thivet,  a  patient 
read  whole  words  upon  a  blank  surface  that  was  presented 
to  him. 

*  Joffroy.  Les  hallucinations  unilaterales.  Arch,  de  neurol.,  1896, 
No.  2.  —  Mariani.  Un  cas  d' hallucination  unilaterale.  Riforma 
medica,  1899,  Nos.  30  and  31. 


36  MANUAL  OF   PSYCHIATRY. 

B.    SPECIAL     FEATURES     OF     EACH     VARIETY     OF     HALLU- 
CINATIONS. 

Hallucinations  of  hearing.  —  In  pathological  states,  as 
in  the  normal  state,  auditory  sensations  occupy  a  posi- 
tion of  primary  importance  among  the  psychic  func- 
tions; thus,  of  all  hallucinations  those  of  hearing  are 
clinically  the  most  frequent  and  the  most  important. 

Seglas  *  classifies  them  in  three  categories:  "Ele- 
mentary auditory  hallucinations,  consisting  of  simple 
sounds;  common  auditory  hallucinations,  consisting  of 
sounds  referable  to  definite  objects;  and  finall}'^  verbal 
auditory  hallucinations,  consisting  of  words  represent- 
ing ideas." 

Wernicke  ^  combines  the  first  two  categories  under 
the  name  of  akoasms,  and  designates  the  third,  the 
only  one  that  seems  to  him  to  merit  separate  considera- 
tion, by  the  name  of  phonemes. 

Akoasms  comprise  imaginary  noises  of  a  variable 
nature,  such  as  buzzing,  whistling,  screaming,  groan- 
ings,  ringing  of  bells,  explosions  of  firearms,  etc.  Their 
clinical  significance  is  the  same  as  that  of  hallucinations 
in  general,  and  their  influence  upon  the  mind  depends 
upon  their  interpretation  by  the  i)atient. 

Phonemes  (the  verbal  auditory  hallucinations  of 
Seglas)  have  on  the  contrary  a  special  significance,  in- 
asmuch as  they  consist  of  "words  rej)roscnting  ideas." 
Their  influence  is  much  more  direct  and  much  more 
powerful  than  that  of  akoasms, 

'  LcronH  rliniques  sur  Ics  mtiladics  meniales  ct  nerrcuscs,  p.  5.  — • 
Pathogt'iiir  ct  phjjs-iologie  paUiologique  de  VhalluciiKition  de  I'ouie. 
Coiif^n's  df's  inodpcins  alienistes  et  npurologistos,  1S!)7. 

'  Lor.  cit.,  p.  189. 


SYMPTOMATOLOGY.  37 

Their  content  varies  from  isolated  words  to  the 
most  complicated  discourses.  Sometimes  the  words 
or  phrases  are  pronounced  indistinctly,  resembhng  a 
faint  murmur;  at  other  times  they  are  perceived  with 
remarkable  clearness.  "  It  seems  to  me,"  patients 
often  say  "  that  somebody  is  speaking  very  near  me.  .  . 
I  hear  my  enemies  as  well  as  I  hear  you."  This  dis- 
tinctness largely  accounts  for  their  being  accepted  as 
real  voices,  and  explains  partly  the  remarkable  influence 
of  auditory  hallucinations. 

The  "  invisible  ones,"  as  the  patients  often  call  the 
imaginary  voices,  are  sometimes  localized  with  extraor- 
dinary precision.  "  The  insane  manifest  a  power  of 
localization  not  encountered  in  other  than  patho- 
logical states."  ^  The  distance  at  which  they  believe 
they  hear  the  voices  is  very  variable;  the  voices  may 
be  very  close  by  or,  on  the  contrary,  hundreds  of  miles 
away.  Many  patients  hold  the  persons  that  are  around 
them  responsible  for  the  hallucinations;  thus  are 
explained  some  of  the  sudden  assaults  often  com- 
mitted by  such  patients.  Others  ascribe  their  hallu- 
cinations to  inanimate  objects.  One  patient  accused 
her  needle,  another  her  stockings.  Still  others  lay 
the  blame  upon  invisible  instruments  which  are  used 
by  their  enemies  (phonographs,  telephones,  megaphones, 
etc.). 

Like  all  other  hallucinations,  those  of  hearing  vary 
with  the  nature  of  the  mental  trouble:  sad  in  the 
painful  states,  agreeable  and  cheerful  in  the  expansive 
states.  Usually  the  names  by  which  the  patients 
designate  the  "  invisible  ones  "  are  not  very  choice  ones, 

'  Wernicke.     Loc.  cit.,  p.  205. 


38  MANUAL   OF   PSYCHIATRY. 

consisting  chiefly  of  profane  or  even  filthy  expres- 
sions. Unpleasant  hallucinations  may  alternate  with 
agreeable  ones  in  the  manner  of  attack  and  defense, 
as  has  already  been  stated.  Sometimes  6ach  of  the 
two  varieties  of  hallucinations  is  perceived  by  only 
one  ear. 

The  voices  may  repeat  the  thoughts  of  the  patient, 
even  before  he  has  a  chance  to  express  them.  "  They 
know  before  I  do  what  reply  I  wish  to  make,"  said 
one  such  patient.  Another  said:  ''When  I  read  they 
read  at  the  same  time  and  repeat  every  word."  Many 
complain  that  their  thoughts  are  stolen  from  them.^ 

Quite  often  the  voices  create  neologisms  the  meaning 
of  which  may  remain  absolutely  enigmatical  to  the 
patient  himself,  or  to  which  he  may  attribute  a  signifi- 
cance which  harmonizes  with  his  psychical  state. 

The  timbre  of  the  voices  is  very  variable.  In  some 
cases  the  patient  always  perceives  one  and  the  same 
voice;  but  more  frequently  many  voices  are  heard: 
voices  of  men,  women,  and  children,  which  are 
sometimes  unknown  to  the  patient,  at  other  times 
familiar,  enabling  him  to  establish  the  identity  of  his 
persecutors. 

Although  they  are  encountered  in  a  great  many  mental 
affections,  acute  and  chronic,  hallucinations  of  hearing, 
if  they  constitute  a  prominent  feature  by  reason  of  their 
multiplicity,  distinctness,  or  intensity,  usually  point 
to  a  grave  prognosis.  Their  occurrence  in  an  acute 
psychosis  often  forel^odes  a  particularly  long  duration 
of  the  disease. 

'  Bechtorow.  IJchcr  das  Ilorrn  dcr  eujcnen  Gedankcu.  Arch.  f. 
Psychiatrio,  Vol.  XXX. 


SYMPTOMATOLOGY.  39 

Hallucinations  of  sight.  —  Hallucinations  of  sight 
chiefly  occur  in  toxic  and  febrile  deliria  and  in  certain 
neuroses  (hysteria,  epilepsy,  chorea). 

They  vary  greatly  in  distinctness.  At  times  they 
are  so  clear  that  the  patient  is  able  to  make  a  sketch 
of  them;  often  they  are,  on  the  contrary,  vague  and 
uncertain. 

Like  the  voices,  the  visions  are  apt  to  be  taken  for 
reality  by  the  subject;  he  seeks  to  remove  them,  to  shun 
them,  or  on  the  contrary  to  seize  them.  They  are 
in  such  cases  coupled  with  a  more  or  less  marked  cloud- 
ing of  the  intellect. 

Many  patients,  on  the  contrary,  consider  their  hal- 
lucinations as  artificial  phenomena.  The  more  con- 
scious and  the  clearer  in  mind  the  patient  is,  the  more 
apt  he  is  to  recognize  the  difference  between  the  real 
world  and  his  visions,  because,  with  the  exception 
of  the  cases  in  which  the  consciousness  is  profoundly 
disordered,  visual  hallucinations  "  seldom  bear  the 
appearance  of  reality."  ^  They  lack  the  proper  qualities 
of  normal  visual  sensations:  perspective,  clearness 
of  contour,  variety  of  tints,  etc.  Often  the  morbid 
image  appears  in  a  single  plane,  hazy  in  outline,  and 
grayish  in  color.  It  is  therefore  not  surprising  that, 
not  possessing  the  attributes  of  true  perceptions, 
visual  hallucinations  are  often  not  taken  for  reality, 
and  do  not  exercise  upon  the  mind  of  the  patient  the 
same  degree  of  influence  as  do  phonemes. 

Some  patients  consider  their  hallucinations  as  shadows 
or  images  which  they  are  made  to  see  artificially  by  means 
of  projecting  apparatus,  electric  currents,  etc.     Others 

'  'Wernicke.     Loc.  cit.,  p.  194. 


40  MANUAL  OF   PSYCHIATRY. 

attribute  them  to  the  pernicious  action  of  poisons 
which  their  enemies  make  them  absorb. 

Visual  hallucinations  may  take  the  form,  though 
rarely,  of  verbal  hallucinations  of  vision.  The  patients 
see  words  and  phrases  written  on  tables,  walls,  etc. 
A  subject  of  choreic  insanity  whom  I  have  observed 
in  Joffroy's  cUnic  saw  her  own  name  written  on  her 
apron.  Everybody  is  familiar  with  the  famous  words 
Mene,  mene,  tekel,  wpharsin,  which  the  guests  saw  ap- 
pear upon  the  wall  at  Belshazzar's  feast. 

Hallucinations  of  taste  and  smell.  —  The  senses  of 
taste  and  smell  are  as  closely  associated  in  pathological 
states  as  they  are  in  the  normal  state.  Therefore 
hallucinations  of  these  senses  are  usually  considered 
together. 

Their  clinical  significance  varies,  depending  upon 
whether  they  coexist  with  psychic  and  somatic  dis- 
orders of  an  acute  nature,  or  whether  they  appear  in 
the  course  of  a  chronic  psychosis. 

In  the  first  case  they  often  result  from  the  dryness 
and  the  inflammation  of  the^  nasal  and  buccal  mucous 
membranes  or  glands.  They  disappear  with  the  dis- 
turbances of  these  glands,  and  they  may  be  modified 
very  favorably  by  a}:)propriate  treatment.  Their  im- 
portance with  regard  to  the  prognosis  in  such  cases  is 
very  slight. 

It  is  altogether  different  in  the  second  case,  when 
they  supervene  independently  of  the  above  causes  in 
the  course  of  chronic  affections.  They  almost  always 
indicate  a  [)rofound  alteration  of  the  personality  and 
the  progress  of  the  mental  disorder  towards  dementia. 

Hallucinations  of  taste  and  smell  are  mostly  unpleas- 


SYMPTOMATOLOGY.  41 

ant.  The  patients  complain  of  nauseating  odors; 
putrid  emanations  are  blown  towards  them;  they  are 
made  to  eat  fecal  matter;  poisons  are  poured  into 
their  mouth,  etc.  They  make  use  of  certain  means 
of  defense,  such  as  spitting,  stuffing  the  nostrils  with 
cotton  or  paper,  and,  what  constitutes  a  very  grave 
symptom,  refusal  of  food. 

Hallucinations  of  touch,  of  the  thermal  sense,  and  of  the 
sense  of  pain.  —  These  are  often  placed  in  a  single  group 
under  the  name  of  hallucinations  of  general  sensibility. 

Hallucinations  of  touch  are  frequent  in  certain  toxic 
psychoses  (deUrium  tremens,  cocaine-  dehrium),  and 
in  chronic  delusional  states.  The  patients  feel  the 
breath  of  somebody  or  the  contact  of  something;  they 
feel  as  though  spiders  are  crawling  upon  their  bodies, 
or  they  may  have  a  sensation  of  being  bound  in  an 
entangled  mass  of  cords. 

Closely  related  to  the  above  are  hallucinations  of 
the  genital  sense,  which  are  encountered  in  neuroses, 
chiefly  hysteria,  in  mania,  and  in  a  great  many  other 
acute  and  chronic  psychoses.  They  consist  of  either 
painful  or  voluptuous  imaginary  sensations.  When  they 
co-exist  with  perfect  mental  lucidity  they  generally 
indicate  a  very  grave  prognosis. 

Hallucinations  of  the  thermal  sense  and  of  the  sense  of 
pain  are  a  feature  of  chronic  delusional  states.  The 
patients  complain  of  being  burned  aHve,  that  their 
body  is  being  pierced  with  a  red-hot  iron,  that  they  are 
being  thrown  off  from  their  chair,  that  they  are  made 
to  experience  shocks  like  those  of  electric  discharges,  etc. 

Motor  hallucinations. —  A  motor  hallucination  may  be 
defined  as  an  imaginary  perception  of  a  movement.     It 


42  MANUAL  OF   PSYCHIATRY. 

constitutes  a  disorder  of  that  kind  of  sensibility  which 
has  been  designated  by  the  term  muscular  sense. 

Analogous  phenomena  are  encountered  in  normal 
individuals;  the  sensation  of  heaviness  or  of  lightness 
of  the  limbs,  which  we  experience  during  sleep,  are  justly 
attributed  by  Beaunis  ^  to  disturbances  of  the  mus- 
cular sense;  the  illusions  referred  to  an  amputated  limb 
are  often  accompanied  by  motor  hallucinations. 

Motor  hallucinations  are  frequent  among  the  insane. 
Some  feel  themselves  being  raised  from  their  bed,  being 
shaken  continually  against  their  will,  etc.  Others, 
like  the  mediiDval  sorcerers,  imagine  themselves  flying 
in  the  air. 

By  a  well-known  psychological  process  the  sensation 
tends  to  transform  itself  into  an  act,  the  motor  image 
into  a  movement.  The  motor  hallucination  becomes  an 
impulse.  The  patient  feels  with  astonishment  that  his 
limbs,  his  tongue,  or  his  mouth  become  the  seat  of 
movements  in  which  his  will  takes  no  part.  A  patient 
of  Krishaber's,  for  instance,  felt  his  legs  "  move  as 
though  endowed  w^ith  a  power  other  than  that  of  his 
own  will."  Many  of  the  persecuted  or  mystic  patients 
affirm  that  they  have  been  transformed  into  automatons, 
and  that  God  or  their  enemies,  as  the  case  may  be, 
make  them  go  and  act  as  they  wish. 

There  is  a  certain  form  of  motor  hallucinations 
which  deserves  particular  attention  by  reason  of  its 
frequency,  its  clinical  importance,  and  its  high  psy- 
chological interest;  these  are  the  verbal  motor  hallu- 
cinations   which    have    been    admirably    described    by 


'   Lcs  sensatiom  internes,  1889,  Paris,  F.  Alcan. 


SYMPTOMATOLOGY.  43 

Seglas/  As  their  name  indicates,  they  affect  the  func- 
tion of  speech.  The  patient  is  conscious  of  involuntary- 
movements  of  his  tongue  and  hps,  identical  with  those 
which  produce  articulation  of  words.  The  sensation 
may  exist  alone  or  it  may  acquire  such  intensity  that 
it  is  transformed  into  actual  motion,  and  the  patient 
begins  to  speak  in  spite  of  himself.  Often  the  patho- 
logical movements  are  scarcely  apparent,  being  limited 
to  an  inaudible  whii-jper.  Sometimes  the  impulse  is  so 
strong  that  it  results  in  loud  talking  or  screaming. 
The  remarks  made  by  the  patient  in  such  a  case  may 
be  entirely  discordant  with  his  true  sentiments.  In 
this  way  such  patients  may  unintentionally  insult  their 
relatives,  making  use  of  obscene  language,  blasphemies, 
etc.  At  other  times  the  thoughts  of  the  patient  are 
spoken  out  in  spite  of  himself.  Pierracini  has  termed 
this  phenomenon  ''the  escape  of  thought."  (Quoted  by 
Seglas.) 

^^erbal  motor  hallucinations  exercise  upon  the  function 
of  speech,  even  in  those  cases  in  which  they  do  not 
reach  the  stage  of  actual  articulatory  movements,  so 
powerful  an  inhibitory  influence  that  the  subject  be- 
comes totally  unable  to  speak.  This  is  in  perfect  accord 
with  the  observation  of  Strieker,  who  found  that  two 
verbal  motor  images  cannot  exist  at  the  same  time. 
Already  occupied  by  the  hallucinatory  motor  image,  the 
consciousness  remains  closed  to  normal  motor  images. 
Verbal  motor  hallucinations  are  thus  a  cause  of  mutism. 
Graphic  motor  hallucinations  affect  written  speech. 

'  herons  diniques.      Also  Les  troubles  du  langage  chez  les  alienes. 
(Bibliotheque  Charcot-Debove.) 


44  MANUAL  OF   PSYCHIATRY. 

"  The  graphic  image  then  comes  into  play,  and  in  con- 
sequence of  the  morbid  irritabihty  of  the  special  cortical 
centre  for  written  speech  the  patient  has  the  exact  per- 
ception of  a  word  with  the  aid  of  the  representations  of 
the  co-ordinate  movements  which  would  accompany  it 
if  he  were  really  writing  the  word."  ^ 

When  this  morbid  irritation  attains  a  certain  degree 
of  intensity  the  hallucination  becomes  a  graphic  impulse 
and  gives  rise  to  automatic  writing,  which  is  often  met 
with  in  the  "  writing  mediums." 

The  interpretation  of  motor  hallucinations  varies  in 
different  patients.  Some  complain  that  their  enemies 
govern  their  tongues  by  means  of  invisible  wires.  Others, 
feeling  themselves  no  longer  masters  of  their  own  or- 
gans, are  naturally  led  to  think  that  a  strange  personality 
has  become  established  alongside  of  themselves.  Some 
of  the  "  possessed  "  of  the  mediaeval  times  undoubtedly 
had  motor  hallucinations. 

Motor  hallucinations  generally  involve  a  grave  prog- 
nosis. They  indicate  an  already  advanced  disaggre- 
gation of  the  personality.  Therefore  they  are  chiefly 
encountered  in  the  chronic  psychoses;  they  may  appear, 
however,  in  certain  acute  psychoses,  such  as  melan- 
cholia (Seglas)  and  alcoholic  delusional  insanity, 
(Vallon,  C()lolian).2 

Theories  of  hallucinations.  —  I  shall  but  mention 
the  so-called  psychological  theory,  according  to  which 
hallucinations  are  supposed  to  be  a  phenomenon  purely 
of  ideation.     Physicians  and  physiologists  have  long  ago 

'  S(^glas.     Left  troxihlat  du  langage,  p.  246. 

'  Cololian.  Le.s  hallucinatinns  pftycho-motrices  verbales  dans 
I'alcoolifsme.     Arch,  do  Neurol.,  Nov.  1899. 


SYMPTOMATOLOGY.  45 

abandoned  this  theory.  But  though  all  authors  to- 
day admit  the  existence  of  a  material  pathological  pro- 
cess as  the  foundation  of  hallucinations,  they  are  far 
from  being  in  accord  as  to  its  nature  and  as  to  its 
seat. 

Jean  Muller  is  of  the  opinion  that  hallucinations  are 
the  consequence  of  abnormal  irritation  of  the  periphe- 
ral sensory  organ. 

According  to  Meynert  they  result  from  the  automatic 
activity  of  the  subcortical  cerebral  centers,  which  are 
no  longer  inhibited  by  the  cerebral  cortex  as  they  are 
in  the  normal  state. 

The  primary  cause  of  hallucinations  would  thus  be  a 
suppression  of  the  inhibitory  power  of  the  cortex,  which 
is  one  of  the  manifestations  of  cortical  paralysis.  The 
hallucination  is  then  the  consequence  of  a  supremacy 
of  the  inferior  cerebral  functions  over  the  higher  ones. 

Finally,  according  to  Tambourini,  whose  opinion  is 
to-day  the  most  widely  accepted  one,  hallucinations 
are  produced  by  the  automatic  activity  of  a  psycho- 
sensory 'projection-center. 

Under  what  conditions  does  the  automatism  of  the 
projection-center  come  into  play?  Is  it  under  the 
influence  of  direct  irritation  resulting,  for  instance, 
from  a  tumor  or  from  a  circumscribed  patch  of  menin- 
gitis locaHzed  exactly  at  this  center?  Such  cases  occur. 
Serieux  ^  has  observed  verbal  motor  hallucinations  in 
a  general  paretic  in  whose  case  the  autopsy  showed  a 
predominance  of  the  lesions  of  meningo-encephalitis  at 
the  level  of  the  lower  portion  of  the  left  third  frontal 

'  Sur  un  cas  d'haUucination  motrice  verhale  chez  une  paralytique 
generate.     Bull,  de  la  soc.  de  med.  ment.  de  Belgique,  1894. 


46  MANUAL   OF  PSYCHIATRY. 

convolution.  The  lesion  must  not,  however,  be  a  too 
destructive  one.  "  Indeed,  for  a  center  to  be  able  to 
produce  hallucinations,  it  is  necessary  that  conditions 
of  integrity  be  preserved  sufficient  to  permit  its  activity  '* 
(Joffroy).i 

Most  frequently,  however,  the  center  of  projection  is 
not  the  seat  of  any  demonstrable  lesion.  It  seems,  then, 
that  in  most  cases  the  hallucinations  are  the  conse- 
quence, not  of  a  direct  irritation  of  the  psychosensory 
center  itself,  but  rather  of  an  indirect  irritation  coming 
from  another  portion  of  the  cortex.  This  exj)lains 
why  hallucinations  are  always  a  secondary  phenomenon, 
and  why  they  arc  but  an  expression,  a  reflection  of 
the  pathological  preoccupations  of  the  patient. 

Wernicke  has  conceived  a  very  ingenious  theoiy  of 
hallucinations,  founded  upon  his  general  hypothesis  of 
sejunction.  By  this  term  he  designates  a  temporary 
or  permanent  interruption  of  the  paths  followed  nor- 
mally by  a  nervous  impulse.  This  impulse  cannot 
pass  on  freely,  and  accumulates  above  the  point  of  the 
lesion  like  the  water  in  a  river  above  a  dam.  When 
this  accumulation  occurs  in  a  psychosensory  projection- 
center  it  sets  uj)  there  a  state  of  abnormal  irritation  of 
which  the  clinical  expression  is  a  hallucination. 

^  Les  hallnrindlion.'^  uniUitcralrf:.  —  Sicl>ort  has  also  reported  a  case 
in  which  very  pronounced  lialhicinations  of  the  sense  of  smell 
persisted  for  a  lonfi^  time  and  subsequently  disappeared  by  degrees. 
At  the  auto[)sy  the  hippocampus  was  found  to  be  destroyed  by  a 
tumor.  The  author  supposes  that  the  hallucinations  were  caused 
by  irritation  of  the  center  in  question  by  the  growth,  and  that  they 
did  not  cease  until  this  center  was  destroyed.  (Monatschr.  fiir 
Psych,  u.  Neurol.,  Vol.  VI.) 


CHAPTER  III. 

SYMPTOMATOLOGY    {Continued). 

CONSCIOUSNESS.  —  MEMORY.  —  VOLUNTARY  ASSOCIA- 
TION OF  IDEAS.  —  ATTENTION.—  AUTOMATIC  ASSO- 
CIATION OF  IDEAS.  — JUDGMENT. 

§  1.  Disorders  of  Consciousness. 

Consciousness  may  be  lost :  unconsciousness;  or  weak- 
ened: clouding  of  consciousness;  or  exaggerated :  %per- 
consdousness. 

Unconsciousness  and  clouding  of  consciousness.  — 
Unconsciousness  exists  physiologically  in  dreamless 
sleep,  and  pathologically  in  coma  and  in  complete 
stupor. 

Clouding  of  consciousness  represents  the  fundamental 
element  of  many  psychoses.  It  is  always  coupled  with 
more  or  less  complete  disorientation. 

A  complete  orientation  implies  the  integrity  of  the 
following  three  notions: 

1.  The  notion  of  our  own  personality  (autopsychic 
orientation  of  Wernicke); 

2.  The  notion  of  the  external  world  (allopsychic 
orientation  of  the  same  author); 

3.  The  notion  of  time. 

These  three  notions  may  disappear  together  or 
singly.     We  shall  see  later  that  in  certain  affectioms, 

47 


48  MANUAL  OF   PSYCHIATRY. 

notably  in  delirium  tremens,  the  orientation  of  time 
and  place  is  lost,  while  that  of  personality  remains  intact. 
The  patient  is  ignorant  of  the  fact  that  he  is  in  a 
hospital  ward,  does  not  appreciate  his  surroundings,  and 
cannot  give  even  approximately  the  real  date.  But 
he  knows  that  he  is  Mr.  X.,  following  such  and  such  an 
occupation,  so  and  so  many  years  old,  born  on  such 
and  such  a  day,  etc. 

Allopsychic  disorientation,  or  loss  of  the  notion  of 
the  external  world,  is  often  coupled  with  many  hallu- 
cinations. Some  authors  see  in  the  two  symptoms  a 
causative  relation;  the  hallucinations  transport  the 
patient  to  an  imaginary  world,  thus  making  him  lose 
the  notion  of  the  real  world.  Experience  does  not  bear 
out  this  hypothesis:  1)  because  the  orientation  may  be 
perfectly  preserved  in  spite  of  intense  and  unceasing 
hallucinations;  2)  because,  inversely,  it  may  be  pro- 
foundly disordered  without  there  being  hallucinations 
of  any  kind;  3)  because  in  most  of  the  cases  in  which 
these  two  symptoms  are  associated  the  disorientation 
precedes  the  psychosensory  disturbances. 

Influence  of  enfeeblement  of  consciousness  upon  the 
emotional  state  and  upon  the  reactions. — Unconscious- 
ness and  clouding  of  consciousness  find  expression,  in 
the  emotional  sphere,  in  indifference  and  dullness;  and, 
in  the  psychomotor  sphere,  in  aboulia  which  in  extreme 
cases  may  amount  to  complete  inaction. 

If  complicated  by  symptoms  of  excitement,  hallu- 
cinations and  illusions,  delusions,  or  anxiety,  clouding 
of  consciousness  is  accompanied  by  emotional  phenom- 
ena and  reactions  characteristic  of  these  symptoms. 
It  is  important  to  remember  above  all  that  the  disorder 


SYMPTOMATOLOGY.  49 

of  consciousness  may  impart  to  the  reactions  of  the 
patient  a  more  or  less  impulsive  character;  hence  their 
brutal  and  sometimes  ferocious  nature. 

Diagnosis  of  enfeeblement  of  consciousness. — Uncon- 
sciousness is  generally  apparent  from  the  absolute 
indifference  of  the  subject  who  fails  to  react  even  to  the 
strongest  stimulation.  However,  it  is  necessary  to 
exercise  great  caution  in  many  cases.  We  shall  see 
later  on  that  certain  patients,  the  catatonics,  present 
every  appearance  of  unconsciousness  and  may  never- 
theless preserve  perfect  lucidity;  the  disorder  of  con- 
sciousness is  here  only  a  seeming  one.  Often  one  is 
obliged  to  wait  before  coming  to  a  decision;  when  the 
attack  passes  off,  the  patient  himself  may  tell  of  his 
former  condition,  either  declaring  that  he  has  no  recol- 
lection of  what  passed  during  the  attack, — in  which 
case  the  unconsciousness  was  real, — or  explaining  that, 
though  perceiving  the  external  impressions,  he  was  un- 
able to  react, —  in  which  case  the  unconsciousness  was 
but  a  seeming  one. 

Clouding  of  consciousness  is  determined  by  putting 
to  the  subject  a  series  of  questions  concerning  his  age, 
his  occupation,  the  date,  the  surroundings,  and  the 
persons  about  him. 

States  of  obscuration. —  By  this  term  are  designated 
those  pathological  states  in  which  lowered  consciousness 
is  the  dominant  feature.  States  of  obscuration  vary 
greatly  in  their  aspect,  and  probably  also  in  their  nature. 
All,  however,  possess  one  feature  in  common :  they  leave 
behind  almost  complete  amnesia  for  the  occurrences 
that  have  taken  place  during  their  entire  duration. 
But  the  degree  of  consciousness  at  the  time  of  the  attack 


50  MANUAL  OF  PSYCHIATRY. 

itself  is  very  difficult  to  determine,  and  probably  varies 
greatly. 

Often  patients  afflicted  with  violent  delirium  have 
but  an  extremely  confused  notion  of  their  surroundings, 
and  their  acts  bear  the  character  of  complete  automa- 
tism.    Such  are  cases  of  epileptic  dehrium. 

Others,  on  the  contrary,  perform  complicated  acts, 
such,  for  instance,  as  are  involved  in  a  long  voyage,  in 
a  sober  and  reasonable  manner  and  without  attracting 
anybody's  attention;  and  still  they  may  have  no  sub- 
sequent recollection  of  these  acts.  This  occurs  in 
certain  pathological  absences  which  are  most  commonly 
observed  in  epilepsy  but  which  may  also  be  encountered 
in  various  psychoses. 

It  can  scarcely  be  assumed  that  in  these  two  cases 
the  disorders  of  consciousness  are  identical. 

Exaggeration  of  consciousness.  —  Morselli  distin- 
guishes two  kinds  of  hyperconsciousness :  "  Hyper- 
consciousness  with  diffuse  introflection,  when  the 
self-consciousness  is  referred  to  organic  phenomena, 
as  in  melancholiacs,  hypochondriacs,  and  paranoiacs, 
giving  rise  to  illusions  and  hallucinations  of  general 
sensibility  and  of  ccrnaisthesia;  and  hyperconsciousness 
with  concentrated  introflection,  when  representations 
arc  perceived  and  emotions  experienced  with  an  abnor- 
mal intensity:  hence;  the  ecstasy  of  spontaneous  or  in- 
duced (hypnotic)  hallucinatory  states."^  Generally 
hyj)erconsciousness  is  but  partial:  certain  sensations  or 
(•(^itain  representations  absorb  the  conscious  ])sychic 
activity  to  tiie  i)artial  or  complete  exclusion  of  others. 

*  Morselli.     Loc  cit.,  p.  754. 


SYMPTOMATOLOGY.  51 

§  2.  Disorders  of  Memory. 

An  act  of  memory  comprises  three  distinct  operations : 

1.  The  fixation  of  a  representation; 

2.  Its  conservation; 

3.  Its  revival,  that  is  to  say,  its  reappearance  in  the 
field  of  consciousness. 

These  may  be  disordered  together  or  singly;  hence 
the  three  forms  of  amnesia: 

A.  Amnesia  by  default  of  fixation  (or  simply  amnesia 
of  fixation),  also  known  as  anterograde  amnesia; 

B.  Amnesia  of  conservation; 

C.  Amnesia  of  reproduction. 

The  latter  two  affect  impressions  previously  acquired 
and  constitute  retrograde  amnesia;  there  are  there- 
fore two  varieties  of  retrograde  amnesia:  1)  by  default 
of  conservation,  and  2)  by  default  of  reproduction. 

A.  Amnesia  of  fixation.  Anterograde  Amnesia. — The 
power  of  fixation  {Merkfahigkeit  of  German  authors)  is 
dependent  upon  the  distinctness  of  the  preceptions. 
Therefore  all  conditions  in  which  perceptions  are  vague 
and  uncertain  arc  accompanied  by  a  more  or  less  marked 
amnesia  of  fixation;  such  is  the  case  in  epileptic  dehria 
and  in  acute  confusional  insanity. 

Distinctness  of  perception  is  therefore  a  condition 
necessary  for  the  normal  working  of  memory;  it  is, 
however,  not  in  itself  a  sufficient  condition.  An 
imjjression,  though  very  clear  and  very  precise  at  the 
moment,  may  not  fix  itself  upon  the  mind.  Thus  a 
patient  having  the  polyneuritic  psychosis  may  under- 
stand perfectly  the  questions  put  to  him,  execute  properly 
the  orders  that  are  given  him,  so  that  on  a  superficial 


52  MANUAL  OF  PSYCHIATRY. 

examination  lie  may  convey  the  impression  of  a  normal 
individual ;  still  he  preserves  but  an  incomplete  recollec- 
tion, or  none  at  all,  of  the  occurrences  of  the  whole 
period  of  his  illness.  It  seems,  then,  that  for  proper 
fixation  is  required,  besides  sufficient  distinctness  of 
perception,  some  other  condition  the  nature  of  which 
is  as  yet  undetermined. 

B.  Retrograde  amnesia  by  default  of  conservation.^ 
An  impression  fixed  in  memory  is  preserved  for  a 
greater  or  lesser  length  of  time,  depending  upon  its 
nature  and  upon  the  individual  capabilities  of  the 
subject.  The  memory  of  an  important  event  persists 
longer  than  that  of  an  insignificant  one.  Certain  indi- 
viduals possess  a  prodigious  memory,  others  a  very  poor 
one  or  almost  none  at  all;  between  these  two  extremes 
there  are  infinite  gradations. 

The  disappearance,  under  the  influence  of  some 
pathological  cause,  of  impressions  previously  acquired, 
constitutes  what  we  have  termed  amnesia  of  conserva- 
tion. This  destructive,  and  consequently  incurable, 
form  of  amnesia  is  the  principal  factor  of  certain  types  of 
dementia,  and  is  often  the  first  sign  that  warns  the 
patient's  relatives  of  the  beginning  condition. 

The  disappearance  of  impressions  may  be  more  or 
less  complete,  depending  upon  the  nature  of  the  dement- 
ing process.  While  many  precocious  dements  for  a 
long  time  preserve  a  relatively  good  memory,  general 
paretics  and  senile  dements  present  from  the  beginning 
of  their  illness  very  marked  amnesia. 

Amnesia  of  conservation  is  generally  associated  with 
the  other  two  forms  of  amnesia:  amnesia  of  fixation 
and  anniesia  of  reproduction. 


SYMPTOMATOLOGY.  53 

C.  Retrograde  amnesia  by  default  of  reproduction. — 

In  the  normal  state,  an  impression  fixed  and  preserved 
in  the  memory  possesses  the  property  of  being  revived 
under  certain  conditions.  In  pathological  conditions 
this  power  of  reproduction  may  be  suspended:  the 
impressions  exist,  but  they  are  dormant  and  cannot 
be  revived.  This  form  of  amnesia  is  encountered  in 
many  acute  psychoses,  notably  in  manic  depressive 
insanity,  in  acute  confusional  insanity,  and  in  the 
toxic  psychoses.  Its  prognosis  is  of  course  much  more 
favorable  than  is  that  of  the  preceding  form. 

The  course  of  amnesia. — The  onset  may  be  sudden  or 
insidious;  it  is  often  sudden  in  amnesia  of  reproduction, 
— pure  or  associated  with  amnesia  of  fixation, — and 
almost  always  insidious  in  amnesia  of  conservation. 

Amnesia  may  be  stationary,  retrogressive,  or  pro- 
gressive; it  is  stationary  when,  certain  impressions 
having  become  destroyed,  the  defect  persists  without 
increasing;  retrogressi^•e  when  the  impressions,  simply 
dormant,  reappear  little  by  little;  and  progressive 
when,  as  the  pathological  process  advances,  the  number 
of  destroyed  impressions  becomes  greater  from  day  to 
day. 

In  progressive  amnesia  the  disappearance  of  impres- 
sions occurs  not  at  random,  but  in  a  definite  order. 
"  The  progressive  destruction  of  memory  follows  a  logical 
course,  a  law.  It  descends  progressively  from  the  unstable 
to  the  stable:  it  begins  with  recent  impressions  which,  fixed 
imperfectly  upon  the  nervous  elements,  seldom  repeated 
and  therefore  but  feebly  associated  with  others,  represent 
the  organization  in  its  weakest  degree;  it  ends  with  that 
instinctive,  sensory  memory  which,  stably  fixed  in  the 


54  MANUAL  OF   PSYCHIATRY. 

organism  and  having  become  almost  an  integral  part  of 
it,  represents  the  organization  in  its  strongest  degree. 
From  the  beginning  to  the  end  the  course  of  amnesia, 
governed  by  the  nature  of  things,  follows  the  line  of 
least  resistance,  that  is  to  say,  the  line  of  least  organ- 
ization. "  1  In  senile  dementia,  in  which  the  law  of 
amnesia  is  most  perfectly  demonstrated,  the  impres- 
sions of  old  age  are  the  first  to  become  effaced,  later 
those  of  adult  life,  and  finally  those  of  youth  and 
childhood.  Some  of  the  latter  may  remain  intact 
long  after  the  general  ruin  of  the  memory  and  of  the 
other  intellectual  faculties.  It  is  not  uncommon  to 
meet  with  advanced  senile  dements  who,  though 
incapable  of  recollecting  the  existence  of  their  wife  and 
children,  are  still  able  to  relate  with  minute  details 
the  occurrences  of  their  childhood  or  to  recite  correctly 
fragments  from  the  works  of  classic  authors. 

The  law  of  amnesia,  though  always  the  same,  is 
difficult  to  demonstrate  in  those  affections  in  which 
the  enfeeblement  of  memory  progresses  very  rapidly, 
where  many  impressions,  like  other  manifestations 
of  intellectual  life,  disappear  en  masse.  In  general 
paresis  the  course  of  amnesia  is  much  more  rapid 
and  much  less  regular  than  in  senile  dementia.  This 
fact,  as  we  shall  sec,  is  an  important  element  in 
diagnosis. 

Varieties  of  amnesia. — Amnesia  is  said  to  be  partial 
wlieii  it  involves  only  one  class  of  impressions,  for 
instance  ])ro])er  names,  numbers,  certain  s])ecial 
branches    of    knowledge    (music,  mathematics),    or     a 


llil)()t.      The  Discuses  <>j  Mctnirry. 


SYMPTOMATOLOGY.  55 

foreign  language.  A  young  man  coming  out  of  a 
severe  attack  of  typhoid  fever  forgot  completely  the 
English  language,  which  he  had  spoken  fluently  before 
the  onset  of  his  illness.  Other  impressions  were  quite 
well  preserved.  When  it  involves  verbal  images  the 
amnesia  determines  a  particular  form  of  aphasia, 
amnesic  aphasia. 

Amnesia  is  general  when  it  affects  equally  all  classes 
of  impressions.  Most  of  the  progressive  amnesias  are 
general. 

Amnesia  may  be  limited  to  a  certain  period  of  exist- 
ence. In  such  cases  its  onset  is  almost  always  sudden, 
and  it  is  either  anterograde,  or  retrograde  by  default 
of  reproduction. 

Localization  of  recollections. — ^A  recollection  of  an 
occurrence,  once  evoked,  is  usually  easily  localized  by 
us  as  to  its  position  in  the  past.  This  power  of  locali- 
zation disappears  in  certain  psychoses.  The  patients 
cannot  tell  on  what  date  or  even  in  what  year  some 
fact  occurred,  an  impression  of  which  they  have,  how- 
ever, preserved.  The  default  of  localization  in  the 
past  combined  with  a  certain  degree  of  anterograde 
and  retrograde  amnesia  produces  disorientation  of  time. 

Illusions  and  hallucinations  of  memory. — In  an  illu- 
sion of  memory  a  past  event  presents  itself  to  the 
consciousness  altered  in  its  details  and  in  its  relation 
to  the  patient,  and  exaggerated  or  diminished  in  im- 
portance. Thus  one  senile  dement  claimed  to  have 
superintended  the  construction  of  a  Gothic  cathedral 
several  centuries  old,  holding,  as  he  said,  ' '  the  calipers 
in  one  hand  and  the  musket  in  the  other  to  defend 
myself  against  the  Saracens."      Upon  inquiry  it  was 


56  MANUAL  OF  PSYCHIATRY. 

found  that  the  patient  had  really  worked  about  thirty 
years  previously  on  the  restoration  of  an  old  cathedral. 

An  illusion  of  memory  becomes  a  true  hallucination 
when  the  representation  perceived  as  a  recollection 
does  not  correspond  to  any  actual  past  occurrence. 
A  patient  who  had  been  in  bed  during  several  weeks 
related  once  that  on  the  previous  day  he  assisted  at  the 
coronation  of  the  Russian  emperor:  this  is  a  represen- 
tation without  an  object,  an  hallucination  of  memory. 

Illusions  and  hallucinations  of  memory  form  the  basis 
of  pseudo-reminiscences  ^  which  are  met  with  in  many 
psychoses,  especially  in  hysteria  and  in  the  polyneuritic 
psychosis. 

Pseudo-reminiscences  are  not  infrequent  in  certain 
persons  who  are  usually  not  classed  with  psychopaths. 
In  such  cases  the  hallucinations  and  illusions  of  memory 
occur  on  a  basis  of  abnormally  vivid  mental  images 
which  an  inadequate  auto-critique  fails  to  correct. 

In  some  of  the  insane,  pseudo-reminiscences  occur  in 
such  abundance  as  to  constitute  the  principal  symptom 
of  the  disease.  Thus  one  feeble-minded  patient 
imagines  himself  to  have  participated  in  all  the  im- 
portant historical  events  of  his  epoch,  particularly 
in  the  great  military  actions.  He  has  taken  part  suc- 
cessively in  the  campaigns  of  Tonquin,  Madagascar, 
and  Dahomey,  also  in  the  Spanish-American  war  and 
in  the  Boer  war,  serving  in  different  grades,  —  now  as 
corporal,  now  as  sergeant-major,  now  as  colonel.  During 
all  this  time  he  has  had  several  conferences  with  the 

'  Dclbriick.  Die  pathologiKchc  LiUje  uvd  die  psychisch  abnormen 
Schwindler.  —  KocpfxTi.  Ueber  die  patfiologische  Liige  (Pseudologia 
phantastica).     Charit6  Annal.  Jan.  1898. 


SYMPTOMATOLOGY.  57 

Gennan  emperor,  also  with  the  empress,  his  cousin. 
When  his  reminiscence  bears  upon  some  historical  event 
the  patient  gives  details  culled  from  the  magazines  or 
from  popular  books,  and  relates  them  with  a  degree  of 
accuracy  which  indicates  a  good  memory. 

I  shall  mention  lastly  a  curious  form  of  illusion  of 
memory,  which  has  been  designated  by  the  expression 
illusion  of  having  already  seen.  "It  consists  in  a 
belief  that  a  state  of  consciousness  that  in  reality  is 
new  was  experienced  before,  so  that  when  it  first 
occurs  it  is  thought  to  be  a  repetition."  ^  One  patient 
claimed  that  all  the  occurrences  which  he  was  wit- 
nessing had  taken  place  a  year  previously,  day  by  day. 
He  made  a  great  deal  of  noise  at  the  marriage  of 
one  of  his  sisters,  demanding  to  know  why  a  ceremony 
which  had  already  been  performed  a  year  ago  was 
begun  over  again,  and  protesting  that  it  was  like  a 
farce.^ 

Exaltation  of  memory  (Hypermnesia) .  —  This  consists 
in  the  reappearance  in  consciousness,  owing  to  some 
accidental  or  pathological  influence,  of  impressions  which 
have  apparently  become  completely  obliterated. 

Hypermnesia  may  be  general  or  partial. 

General  hypermnesia  is  met  with  in  certain  cases  of 
mania;  sometimes  at  the  onset  of  general  paresis; 
following  the  shock  of  violent  emotions,  —  as  in  the  case 
of  the  man  mentioned  by  Forbes  Winslow,^  who  at 
the  point  of  being  crushed  by  a  train  had  all  the  events 

*  Ribot.     Loc.  cit. 

'  Amaud.      Un  cas  d'illusion  du  deja  vu  ou  de  fausse  memoire. 
Ann.  m6d.  psych.,  May-June,  1896. 
^  Quoted  by  Ribot.      Loc.  cit. 


58  MANUAL  OF   PSYCHIATRY. 

of  his  life  pass  through  his  mind  in  a  sort  of  mnemonic 
panorama;  —  antl  finally,  it  is  said,  in  the  dying, 
preceding  the  lethal  agony. 

Partial  hypermnesia  involves  isolated  and  restricted 
impressions  or  groups  of  impressions,  —  for  instance, 
certain  forgotten  languages.  Such  is  the  case  of  the 
German  and  Swedish  emigrants,  mentioned  by  Rush,V 
who  at  the  moment  of  death  prayed  in  the  language  of 
their  youth,  in  which  they  had  not  spoken  for  sixty 
years. 

§  3.   Attention  and  Association  of  Ideas. 

Disorders  of  attention.  —  Attention  manifests  itself 
in  two  forms:  spontaneous  and  deliberate  or  voluntary. 
Spontaneous  attention,  the  inferior  and  less  complex 
of  the  two  forms,  consists  "in  a  direction  of  the  being 
toward  the  stimulus"  or  "in  a  simple  and  spontaneous 
fixation  of  phenomena."  Deliberate  attention  directs 
the  association  of  ideas;  governs  the  course  of  repre- 
sentations, allowing  each  to  remain  for  a  greater  or 
lesser  length  of  time  in  the  field  of  consciousness;  in 
other  words,  it  brings  about  voluntary  and  conscious 
psychical  activity. 

Complete  paralysis  of  attention  involves  loss  of 
spontaneous  attention  as  well  as  of  voluntary  attention. 
It  coexists  always  with  considerable  weakening  of 
consciousness,  there  being  no  possibility  of  the  produc- 
tion of  any  state  of  consciousness  without  a  certain 
degree  of  at  least  spontaneous  attention. 

Abnormal  mobility  of  attention  consists  in  paralysis 

'  Quoted  by  Ribot.     Loc.  cit. 


SYMPTOMATOLOGY.  59 

of  deliberate  attention,  spontaneous  attention  being 
intact  and  in  most  cases  even  exaggerated.  An  im- 
pression of  any  kind  suffices  to  distract  the  mind  of  the 
subject,  but  no  impression  can  fix  it.  This  pheno- 
menon is  well  illustrated  by  the  following  experiment. 
A  maniac  was  asked  to  tell  about  the  death  of  his  mother, 
which,  incidentally,  was  the  cause  of  his  illness.  He 
began:  "The  poor  woman  came  home  from  her  work 
in  the  evening.  She  was  taken  with  a  chill.  .  .  "  One 
of  the  assistants  picks  up  a  pencil  from  the  table  in  front 
of  the  patient.  "  Hold  on!  there  is  a  pencil,  a  blue 
pencil.  .  .  Can  you  draw?"  Another  assistant  begins 
to  cough.  "  If  you  have  a  cough  you  should  take 
Geraudel's  tablets. . .  You  know,  spitting  on  the  floor  is 
prohibited.  .  .  That's  a  fact.  .  ."  The  first  assistant 
unbuttons  his  coat.  "  I  hope  you  are  not  going  to 
undress  here,  that  would  be  improper! .  .  ."  Noticing 
a  small  rent  in  the  vest  of  the  same  assistant:  "I  guess 
you  have  no  wife  to  do  your  mending!.  .  ."  This 
example  shows  how  the  mind,  deprived  of  the  guidance 
of  voluntary  attention,  drifts  at  the  occasion  of  various 
external  impressions  without  ever  becoming  fixed. 

Disorders  of  association  of  ideas.  — Associations  are 
of  two  kinds:  voluntary  and  automatic.  Voluntary 
associations  are  under  the  control  of  attention  and  are 
effected  in  a  special  order  which  is  determined  by  a 
principal  idea  termed  the  guiding  idea.  Automatic 
associations  are,  on  the  contrary,  produced  spontane- 
ously and  without  any  predominating  idea.  They 
constantly  threaten  to  deviate  the  course  of  voluntary 
associations;  one  of  the  principal  functions  of  deliberate 
attention  consists  in  inhibiting  automatic  associations. 


60  MANUAL  OF  PSYCHIATRY. 

Weakening  of  attention  is  closely  connected  with 
sluggish  formation  of  voluntary  associations.  This  latter 
symptom  is  manifested  clinically  by  slowness  of  appre- 
hension, and  experimentally  by  lengthening  of  reaction- 
time,  that  is  to  say  the  time  required  for  a  sensation  to 
be  transformed  into  a  voluntary  and  conscious  move- 
ment.* 

Weakening  of  attention  and  sluggishness  of  volun- 
tary associations  constitute  the  earliest  and  most  con- 
stant manifestations  of  psychic  paralysis.  Combined 
with  insufficiency  of  perception  and  with  a  more  or  less 
pronounced  disorder  of  consciousness,  they  bring  about 
mental  confusion,  a  syndrome  which  may  occur  as  an 
episode  in  the  course  of  a  great  many  mental  diseases 
and  as  a  permanent  manifestation  of  an  affection  known 
as  primary  mental  confusion. 

The  intensity  of  this  state  may  be  of  three  degrees: 

1st  degree:  diminished  capacity  for  intellectual 
exertion,  rapid  fatigue; 

2d  degree:  intellectual  dullness; 

3(1  degree;  complete  suspension  of  all  voluntary 
intellectual  activity. 

Weakening  of  attention  and  sluggishness  of  asso- 
ciation may  exist  alone,  as  in  certain  forms  of  melan- 
cholia, and  especially  in  stupor,  in  which  they  attain 
their  highest  degree.  They  may  also  be  associated 
with  exaggerated  activity  of  the  mental  automatism, 
which  manifests  itself  by  an  abnormal  mobility  of 
attention  and  by  a  flow  of  incongruous  ideas  (flight 
of  ideas,  incoherence),  or,  on  the  contrary,  by  the  ap- 

'  Pierre  Janet.  Xi'rroses  ft  iilres  fixes,  Paris,  F.  Alcan.  —  Sommer. 
Lehrbuch  der  ]>s>jchopathologischen  U ntersuchungsmethoden,  1899. 


SYMPTOMATOLOGY.  61 

pearance  in  the  field  of  consciousness  of  some  particu- 
larly tenacious  and  exclusive  representation  (impera- 
tive idea,  fixed  idea,  autochthonous  idea). 

Flight  of  ideas.  —  Incoherence.  —  These  two  symptoms 
constitute  two  different  degrees  of  the  same  morbid 
process. 

Flight  of  ideas,  almost  always  dependent  upon  an 
abnormal  mobility  of  attention,  consists  in  a  rapid  suc- 
cession of  representations  which  appear  in  the  field  of 
consciousness  without  any  order,  at  the  occasion  of  ex- 
ternal impressions,  superficial  resemblances,  coexistences 
in  time  or  space,  similarities  of  sound,  etc.  One  word 
arouses  the  idea  of  another  of  a  similar  sound  or 
having  the  same  termination  (association  by  assonance). 
The  following  example  from  a  case  of  a  maniac,  whose 
discourse  during  several  minutes  was  copied  verbatim, 
will  show,  better  than  a  description  could,  the  character 
of  this  pathological  phenomenon: 

"  Now  I  want  to  be  a  nice,  accommodating  patient; 
anything  from  sewing  on  a  button,  mending  a  net,  or 
scrubbing  the  floor,  or  making  a  bed.  I  am  a  jack-of-all- 
trades  and  master  of  none!  (Laughs;  notices  nurse.) 
But  I  don't  hke  women  to  wait  on  me  when  I  am  in 
bed;  I  am  modest;  this  all  goes  because  I  want  to 
get  married  again.  Oh,  I  am  quite  a  talker;  I  work 
for  a  New  York  talking-machine  company.  You  are 
a  physician,  but  I  don't  think  you  are  much  of  a 
lawyer,  are  you?  I  demand  that  you  send  for  a 
lawyer!  I  want  him  to  take  evidence.  By  God  in 
Heaven,  my  Saviour,  I  will  make  somebody  sweat! 
I  worked  by  the  sweat  of  my  brow!  (Notices  money 
on  the  table.)  A  quarter;  twenty-five   cents.     In   God 


62  MANUAL  OF   PSYCHIATRY. 

we  trust;  United  States  of  America;  Army  and  Navy 
forever!" 

Flight  of  ideas  was  formerly  considered,  especially  in 
mania,  the  result  of  excessive  activity  of  the  normal 
intellectual  function;  it  was  believed  that  the  patient, 
unable  to  express  in  words  the  ideas  which  crowd 
themselves  into  his  consciousness,  is  compelled  to  leave 
out  a  large  number  of  them,  and  that  these  omissions 
cause  the  disconnectedness  of  his  (Uscourse. 

In  reality  this  exaggerated  activity  affects  only  the 
automatic  intellectual  functions  and  is  always  associated 
with  an  enfeeblement  of  the  higher  psychic  functions. 
The  esscntiar  cause  of  the  phenomenon  is  to  be  looked 
for  in  a  weakness  of  attention:  representation  A  cannot 
fix  itself  in  consciousness  and  is  immediately  replaced 
by  representation  B,  and  so  on. 

While  in  flight  of  ideas  the  representations  are  still 
associated  by  their  relations,  which  though  superficial 
are  yet  real,  in  incoherence  they  follow  each  other 
without  any  even  apparent  connection.  The  following 
is  a  specimen  of  incoherent  speech  obtained  from  a 
case  of  dementia  pra^cox:  "  What  liver  and  bacon  is 
I  don't  know.  You  are  a  spare;  the  spare;  that's  all. 
It  is  Aunt  Mary.  Is  it  Aunt  Mary?  Would  you  look 
at  the  thing?  Wliat  would  you  think?  Cold  cream. 
That's  all.  Well,  I  thought  a  comediata.  Don't 
worry  about  a  comediata.  You  write.  He  is  writing. 
Shouldn't  write.  That's  all.  I'll  hot  you  have  a  lump 
on  your  back.  That's  all.  I  looked  out  the  window 
and  I  didn't  know  what  underground  announcements 
are.     My  husband  had  to  take  dogs  for  a  fit  of  sickness." 

These  few  lines  suffice  to  show  the  profound  degree 


SYMPTOMATOLOGY.  63 

of  psychic  disaggregation  which  is  manifested  by  this 
phenomenon. 

It  is  not  uncommon  for  the  two  symptoms,  flight  of 
ideas  and  incoherence,  to  appear  in  succession,  or  even 
together,  in  the  same  subject,  notably  in  cases  of  mania, 
in  acute  mental  confusion,  also,  though  less  often,  in 
dementia  prsecox. 

Imperative  idea.  —  Fixed  idea.  —  Autochthonous  idea/ 
—  We  have  stated  above  that  mental  automatism 
may  manifest  itself  by  the  appearance  of  an  idea  that 
is  particularly  tenacious  and  exclusive,  occupying  by 
itself  the  field  of  consciousness,  from  which  nothing  can 
dislodge  it.^ 

The  three  forms  in  which  this  phenomenon  may  appear 
have  been  well  defined  by  Wernicke.^ 

An  imperative  idea  imposes  itself  upon  the  patient's 
consciousness  against  his  own  will;  he  recognizes  its 
pathological  character  and  seeks  to  rid  himself  of  it. 
It  is  a  parasitic  idea,  recognized  as  such  by  the  patient. 

A  mother  is  haunted  by  the  idea  of  killing  her  child 
whom  she  loves  dearly.  As  she  herself  states,  she  can 
no  longer  think  of  anything  else;  but  she  recognizes 
it  as  a  morbid  phenomenon  and  begs  to  be  relieved  of 
it:  this  is  an  imperative  idea. 

A  fixed  idea,  on  the  contrary,  harmonizes  with 
the  other  representations.  Therefore  it  is  never  con- 
sidered by  the  subject  as  foreign  to  the  mind  or  as  a 
pathological  phenomenon. 

1  Milne  Bramwell.  On  Imperative  Ideas.  Brain,  1895.  — 
Keraval.     L'idee  fixe.     Arch,   de  Neurol.,    1899,   Nos.   43  and  44. 

^  This  form  of  mental  automatism  may  be  termed  morwideal 
automatism. 

'  Loc.  cit.,  p.  108. 


64  MANUAL  OF   PSYCHIATRY. 

A  mother  who  has  lost  her  child  is  convinced  that  if 
she  had  given  it  a  certain  kind  of  medicine  the  child 
would  not  have  died.  This  idea  does  not  leave  her, 
appears  to  her  perfectly  legitimate  and  natural:  this  is 
a  fixed  idea. 

Fixed  ideas  form  the  basis  of  certain  delusional  states, 
notably  that  of  paranoia.  They  are  also  the  starting 
point  of  a  great  many  hysterical  episodes.  In  such 
cases  they  are  often  subconscious,  that  is  to  say,  they 
exercise  their  influence  without  the  patient's  being 
conscious  of  their  existence. 

Fixed  ideas  are  not  found  exclusively  in  cases  of 
mental  aUenation;  they  are  encountered  in  the  normal 
state  as  certain  tendencies  that  may  be  in  themselves 
perfectly  legitimate.  Such  are  the  desires  for  ven- 
geance, ambition,  etc. 

Autochthonous  ideas,  like  imperative  ideas,  are  de- 
veloped alongside  of  normal  associations.  The  only 
difference  is  in  the  patient's  interpretation  of  them; 
while  the  imperative  idea  is  recognized  by  him  as 
pathological,  the  autochthonous  idea  is  attributed  to 
some  malevolent  influence,  most  frequently  to  some 
strange  personality.  If  he  complains,  it  is  to  the 
police  officer  and  not  to  the  physician.  A  mother 
believes  that  her  neighbor  forces  upon  her  the  idea 
of  killing  her  child :  this  is  an  autochthonous  idea. 

Closely  related  to  imperative  ideas,  autochthonous 
ideas  present  a  similar  analogy  to  hallucinations;  like 
hallucinations,  they  Insult  from  the  automatic  activity 
of  a  cortical  center.  But,  instead  of  playing  upon  a 
psychosensory  center,  the  morbid  irritation  occurs  in  a 
psychic    center.     Baillarger   designated    autochthonous 


SYMPTOMATOLOGY.  65 

ideas  by  the  term  psychic  hallucinations  A  This  term 
has  lately  fallen  into  disuse,  perhaps  undeservedly. 

Nothing  proves  more  conclusively  the  kinship  of  the 
two  classes  of  symptoms  than  the  frequent  transforma- 
tion of  autochthonous  ideas  into  auditory,  motor,  and 
occasionally  even  visual,  verbal  hallucinations.  The 
analogy  between  autochthonous  ideas  and  verbal  motor 
hallucinations  led  Seglas  ^  to  consider  the  two  phenomena 
as  identical  in  their  nature,  the  first  being  but  a  rudi- 
mentary form  of  the  second.  This  opinion  will  appear 
somewhat  exclusive  if  we  take  into  consideration  the 
fact  that  autochthonous  ideas  may  engender  auditory 
hallucinations  ^  just  as  readily  as  motor  hallucinations, 
and  that  in  many  cases  they  are  not  accompanied  by 
even  the  sHghtest  sensation  of  movement. 

Psychic  hallucinations  generally  indicate  advanced 
disaggregation  of  the  personality  and  therefore  point 
to  a  grave  prognosis. 

§  4.   Disorders  of  Judgment. 

Judgment  is  the  act  by  which  the  mind  determines 
the  relationship  between  two  or  more  representations. 

When  the  relationship  is  imaginary  the  judgment 
arrives  at  a  false  conclusion.  This  becomes  a  de- 
lusion when  it  is  in  obvious  conflict  with  evidence. 

False  ideas  which  patients  often  entertain  concern- 
ing their  own  condition,  believing  their  health  to  be 
perfect  when  in  reality  it  is  seriously  afTected,  are  to 

•  Marandon  de  Montyel.  Des  hallucinations  psychiques.  Gaz. 
hebd.  de  Med.  et  de  Chirurgie,  March,  1900. 

*  Le(;ons  climques  sur  les  maladies  mentales  et  rierveuses. 
'  Wernicke.     Loc.  cit. 


66  MANUAL  OF  PSYCHIATRY. 

be  attributed  to  impaired  judgment  [lack  of  insight]. 
This  lack  of  appreciation  of  their  own  condition  is  not 
always  absolute,  and  though  in  general  it  may  be  truly 
said  that  insanity  is  a  disease  which  does  not  recog- 
nize itself,  it  must,  however,  be  acknowledged  that 
sometimes,  chiefly  at  the  onset  of  the  psychoses,  the 
patients  are  conscious  of  pathological  changes  taking 
place  in  them/ 

Some  apply  to  the  physician  of  their  own  accord,  or 
even  request  to  be  committed.  A  sufferer  from  recurrent 
insanity,  treated  several  times  at  the  Clermont  Asylum, 
had  at  the  beginning  of  his  attacks  such  perfect  realiza- 
tion of  his  state  that  he  would  request  by  telegram  to 
have  attendants  sent  after  him. 

General  properties  of  delusions. — ^The  sum  of  a  patient's 
delusions  constitutes  a  delusional  system. 

Such  a  system  may  consist  of  purely  imaginary  ideas, 
or  of  ideas  based  upon  actual  facts  improperly  inter- 
preted. 

In  the  latter  case  we  have  delusional  interpretations. 
A\Tien  the  delusional  interpretations  involve  occurrences 
of  the  past  they  are  termed  retrospective  falsifications. 

Sometimes  a  delusional  state  follows  a  dream,  is  con- 
founded with  it,  and  presents  all  tlie  characteristics  of 
it  (dream  delirmm)  ;.th.is  occurs  in  many  infectious  and 
toxic  psychoses. 

Almost  always  the  delusions  are  multiple.  Even  in 
those  oases  which  are  sometimes  designated  by  the 
term    monomania,    the    primary    morbid    idea    entails 


'  Pick.  Uclicr  Krankhcituhewusstsein  in  pKijcliischen  Krankheiten. 
Arch.  f.  Psychiat.,  Vol.  XIII.  —  Heilhronnor.  Ueber  Kranktieilsein- 
sicht.     Allg.  Zc'itsch.  f.  Psychiat.,  Vol.  LIV.  No.  4. 


SYMPTOMATOLOGY.  .      67 

a  certain  number  of  secondary  morbid  ideas  which 
result  from  it.  In  some  cases  different  delusional 
conceptions  coexist  without  there  being  any  connec- 
tion between  them,  in  others  they  are  grouped  so  as  to 
form  a  more  or  less  logical  whole  possessing  greater  or 
lesser  plausibility.  In  the  first  instance  the  delusions 
are  said  to  be  incoherent,  in  the  second  systematized. 

Whether  systematized  or  not,  delusions,  like  hallu- 
cinations, generally  harmonize  with  the  emotional  tone. 
This  harmony  disappears  when  the  pathological  process 
becomes  abated  in  intensity,  as  the  patient  either 
enters  upon  his  convalescence  or  lapses  into  intellectual 
enfeeblement.  In  dements  the  delusions  often  affect 
neither  the  emotions  nor  the  reactions.  A  patient  may 
claim  that  he  is  an  emperor  and  at  the  same  time 
agree  to  sweep  the  hall;  or  one  may  believe  himself 
to  have  lost  his  stomach  and  still  eat  with  a  hearty 
appetite. 

Three  great  categories  of  delusions  are  usually  dis- 
tinguished : 

Melancholy  ideas ; 
Ideas  of  persecution; 
Ideas  of  grandeur. 

We  shall  limit  ourselves  here  to  a  brief  sketch  of 
these,  reserving  the  details  for  consideration  in 
connection  with  the  affections  in  which  the  delusions 
occur. 

Melancholy  ideas,  — Very  common  at  the  beginning 
of  psychoses,  melancholy  ideas  may  persist  through 
the  entire  duration  of  the  disease,  as  in  involutional 
melancholia. 


68  MANUAL  OF   PSYCHIATRY. 

The  principal  varieties  are: 

(A)  Ideas  of  humility  and  of  culpability.  The 
latter  are  also  called  ideas  of  self-accusation; 

(B)  Ideas  of  ruin; 

(C)  Hypochondriacal  ideas; 

(D)  Ideas  of  negation. 

A.  Ideas  of  humility  and  of  culpability.  —  The  patient 
considers  himself  a  being  good  for  nothing,  wretched, 
undeserving  of  the  attention  bestowed  upon  him,  and 
accuses  himself  of  imaginary  faults  or  crimes.  Often 
he  will  seek  out  from  his  past  life  some  insignificant 
act  to  which  he  will  attribute  extreme  gravity:  he 
stole  some  apples  when  he  was  a  boy,  or  he  forgot  to 
make  the  sign  of  the  cross  once  upon  entering  a  church. 
The  idea  of  the  crime  committed  entails  also  ideas  of 
merited  punishment:  he  expects  every  instant  to  be 
arrested,  put  to  death,  cut  to  pieces,  thrown  into 
hell,  etc. 

B.  Ideas  of  ruin.  —  These  are  frequent  in  senile 
dements;  the  patient  believes  himself  to  be  without 
any  means,  bereft  of  everything;  his  clothes  will  be 
sold;  some  day  he  will  be  found  dead  of  starvation  on 
a  public  road. 

C.  Hypochondriacal  ideas.  —  These  concern  the  sub- 
ject himself,  involving  either  the  physical  sphere  — 
the  stomach  is  obstructed,  the  spinal  marrow  is  softened, 
the  entire  organism  is  affected  by  an  incurable  disease  — 
or  the  psychical  sphere  constituting  psychical  hypo- 
chondriasis: the  mind  is  ]:)aralyzed,  the  intelligence 
is  destroyed,  the  will  power  is  annihilated. 


SYMPTOMATOLOGY.  69 

Hypochondriacal  ideas  are  sometimes  dependent 
upon  an  actual  diseased  condition  which,  however,  is 
falsely  interpreted  by  the  patient  {Hypochondria  cum 
materia).^ 

D.  Ideas  of  negation.^  —  In  some  cases  these  concern 
the  subject  himself,  and  are  then  nothing  but  hypochon- 
driacal ideas  pushed  to  an  extreme:  the  brain,  the 
heart,  etc.,  are  destroyed,  the  bones  are  replaced  by 
air,  the  body  is  nothing  but  a  shadow  without  a  real 
existence.  In  other  cases  they  are  referred  to  the 
external  world:  the  sun  is  dead,  the  earth  is  nothing 
but  a  shadow,  the  universe  itself  exists  no  more  (meta- 
physical ideas  of  negation). 

By  a  singular  process,  apparently  paradoxical,  hypo- 
chondriacal ideas  and  those  of  negation  give  rise  to  ideas 
of  immortahty  and  of  immensity.  The  patient,  feeling 
himself,  on  account  of  the  destruction  of  his  organs, 
placed  beyond  the  laws  of  nature,  concludes  that  he 
cannot  die,  and  that  he  is  condemned  to  suffer  eternally ; 
or,  dismayed  by  the  form  and  monstrous  dimensions 
of  his  body,  he  imagines  himself  obscuring  the  atmos- 
phere, filling  the  world,  etc. 

By  the  expression  syndrome  of  Cotard  has  been 
designated  a  group  of  symptoms  which  is  encountered 

'  Pick.  Zur  Lehre  von  der  Hypochondrie.  Allg.  Zeitscher.  /. 
Psychiat.,  1903,  fasc.  1-2. 

'  Seglas.  Lemons  cUniques,  p.  276.  —  Cotard.  Du  delire  des 
negations.  Arch,  de  neurol.,  1882.  —  Amaud.  Sur  le  delire  des 
negations.  Ann.  med.  psychol.,  Nov.-Dec.  1892.  —  Seglas.  Le 
delire  des  negations.  Encycl.  des  Aide-mem.  —  Trenel.  Notes  sur 
les  idees  de  negation.  Arch,  de  neurol.,  March,  1899.  —  Castin. 
Un  cas  de  delire  hypochondriaque  a  forme  evolutive.  Ann.  med. 
psych.,  June,  1900. 


70  MANUAL   OF   PSYCHIATRY. 

in  certain  cases  of  chronic  melancholic  delusional  states 
the  constituent  elements  of  which  are: 

Ideas  of  negation; 

Ideas  of  immortality  associated  with  ideas  of  damna- 
tion or  of  being  possessed;  ideas  of  immensity; 

MelanchoUc  anxiety; 

Tendency  to  suicide; 

Analgesia. 

The  general  features  of  melancholic  delusional  states 
are  the  expression  of  psychic  inhibition  and  of  the  pain- 
ful emotional  tone  which  constitute  the  basis  of  the 
melanchoUc  state. 

The  following  is  a  summary  of  the  chief  character- 
istics of  these  states,  according  to  the  admirable  study 
of  Seglas : 

a)  Melancholic  delusions  are  monotonous;  the  same 
delusions  are  constantly  repeated,  the  inhibition  allow- 
ing but  little  formation  and  appearance  of  new  ideas. 

h)  These  states  are  humble  and  passive.  The  patient 
accuses  no  one  but  himself,  and  submits  without  resist- 
ance to  the  ill-treatment  which  he  believes  himself  to 
have  deserved. 

c)  As  to  localization  in  time,  the  delusions  are 
referred  to  the  past  and  to  the  future:  the  patient 
finds  in  the  i)ast  the  imaginary  sins  which  he  has  com- 
mitted, and  foresees  in  the  future  the  chastisements 
which  are  to  be  inflicted  upon  him.  In  this  respect 
melancholic  delusional  states  are  in  contrast  with 
persecutory  delusional  states.  The  persecuted  patient 
localizes  his  delusions  chiefly  in  the  present.  The 
persecutions  of  which  he  complains  are  actual. 


SYMPTOMATOLOGY.  71 

d)  From  the  standpoint  of  its  development  the 
melanchoHc  delusional  state  is  centrifugal.  The  trouble 
begins  with  the  subject  himself  and  extends  gradually 
to  his  friends,  to  his  country,  and  to  the  entire  universe, 
who  suffer  through  his  faults. 

e)  The  melanchohc  delusional  state  is  secondary,  that 
is  to  say,  it  is  the  consequence  of  sadness  and  of  psychical 
pain.  It  shares  this  characteristic  with  most  of  the 
other  delusional  'states  which  are  generally  but  the 
expression  of  the  emotional  tone  of  the  subject.^ 

Melanchohc  delusions  may  have  two  grave  conse- 
quences which  I  shall  many  times  have  occasion  to 
emphasize:  suicidal  tendency  and  refusal  of  food. 

Ideas  of  persecution.  —  Like  melancholy  ideas,  ideas 
of  persecution  are  of  a  painful  character.  But  while 
the  melancholiac  considers  himself  a  culpable  victim 
and  submits  beforehand  to  the  chastisements  which  he 
believes  he  has  merited,  the  subject  of  persecution  is 
convinced  of  his  innocence  and  protests  and  defends 
himself. 

Ideas  of  persecution  may  be  divided  into  two  groups, 
according  to  whether  they  are  or  are  not  accompanied 
by  hallucinations. 

Those  of  the  first  group  are  associated  with  halluci- 
nations, generally  of  an  unpleasant  character,  among 
which  auditory  verbal  hallucinations  and  hallucinations 
of  general  sensibility  are  most  prominent.  After  a 
certain  time  the  phenomena  of  psychic  disaggregation 
supervene:  motor  hallucinations,  autochthonous  ideas, 
reduplication  of  the  personality,  etc. 

^  Seglas.     Legons  cliniques. 


72  MANUAL  OF   PSYCHIATRY. 

In  the  second  group  are  ideas  of  persecution 
peculiarly  associated  with  false  interpretations;  any 
chance  occurrence  is  ascribed  by  the  patient  to  malevo- 
lence; he  sees  in  everything  evidences  of  hostility 
against  him,  and  attributes  to  the  most  ordinary  and 
unimportant  facts  and  actions  a  significance  which  is 
as  grave  as  it  is  fanciful.  This  form  of  ideas  of  perse- 
cution is  frequent  at  the  onset  of  certain  psychoses; 
it  also  constitutes  the  basis  of  an  afifection  known  as 
paranoia  or  reasoning  insanity. 

Some  patients  do  not  know  their  persecutors.  Others 
accuse  some  particular  persons  or  societies  (Jesuits, 
Freemasons).  Still  others  bear  their  hatred  towards 
some  certain  individual  whd is,  in  their  eyes,  the  instiga- 
tor of  all  the  injurious  procedures  of  which  they  are  the 
victims,  "  the  great  master  of  the  persecutions,"  as 
one  such  patient  once  said. 

Of  all  delusions  those  of  persecution  are  the  most 
irreducible  and  are  held  by  the  patients  with  the  most 
absolute  conviction.  Almost  always  the  patients 
resent  to  have  them  disputed.  In  themselves  these 
delusions  do  not  have  an  invariable  influence  upon  the 
prognosis,  excepting  that,  in  a  very  general  way,  they 
are  of  more  serious  import  than  melancholy  ideas. 

Of  all  delusions  tliese  also  present  the  greatest  tendency 
to  systematization  and  to  progressive  evolution.  A  [per- 
fect persecutory  delusional  system  should  comprise: 

(a)  A  precise  idea  of  the  nature  of  the  persecutions; 

(b)  An  exact  knowledge  of  the  persecutors,  of  their 
aim,  and  of  the  means  employed  by  them; 

(c)  A  plan  of  defense  in  harmony  with  the  nature  of 
the  delusions. 


SYMPTOMATOLOGY.  73 

In  the  examination  of  cases  with  persecutory  ideas 
one  should  always  attempt  to  determine  these  points, 
on  account  of  their  great  practical  importance. 

Ideas  of  grandeur.  —  Ideas  of  grandeur  appear  chiefly 
in  demented  states  and  are  often  of  a  particularly 
absurd  nature,  bearing  the  stamp  of  intellectual  en- 
feeblement.  The  patients  are  immensely  rich,  all- 
powerful;  they  are  popes,  emperors,  creators  of  the 
universe.  Generally  they  naively  claim  these  pom- 
pous titles  without  being  at  all  concerned  by  the  fla- 
grant contradiction  existing  between  their  actual  state 
and  their  ostensible  almightiness.  A  general  paretic 
was  once  asked:  "  If  you  are  God,  how,  then,  does  it 
happen  that  you  are  locked  up?"  "  Because  the  doctor 
refuses  to  let  me  go,"  he  repHed  simply.  It  is  not 
rare  to  see  a  pseudo-pope  obey  without  a  murmur 
the  orders  of  hospital  attendants  and  assist  with  the 
best  possible  grace  in  the  most  menial  labor. 

Often  the  patient's  attire  is  in  harmony  with  the 
title:  uniforms  of  the  oddest  fancy,  multicolored  tin- 
sels, numerous  decorations,  etc. 

When  the  intellectual  enfeeblement  is  less  pro- 
nounced, as,  for  instance,  in  certain  cases  of  dementia 
praecox,  the  subject  shows  more  logic  in  his  conduct. 
He  assumes  an  air  of  dignity,  avoids  all  association 
with  the  other  patients,  and  decHnes  \\'ith  a  contemptu- 
ous smile  all  suggestions  of  employment. 

Ideas  of  grandeur  are  also  met  with  in  certain  acute 
psychoses,  as  in  mania,  for  instance,  and  in  certain 
forms  of  systematized  delusional  states  without  intel- 
lectual enfeeblement  (Paranoia  originaire  of  Sander). 


CHAPTER  IV. 
SYMPTOMATOLOGY  (Continued). 

AFFECTIVITY.— REACTIONS.— C(ENESTHESIA— NOTION 
OF  PERSONALITY. 

§  1.  Disorders  of  Affectivity. 

Pathological  modifications  of  affectivity  are  en- 
countered in  the  course  of  all  psychoses.  They  always 
appear  early,  and  often  before  any  of  the  other  symp- 
toms. 

The  principal  ones  are: 

(a)  Diminution  of  affectivity:    morbid  indifference; 

(h)  Exaggeration  of  affectivity; 

(c)  Morbid  depression; 

(d)  Morbid  anger; 

(e)  Morbid  joy. 

Diminution  of  affectivity. — In  its  most  pronounced 
degree  indifference  involves  all  the  emotions,  as  in 
extreme  states  of  dementia  (general  paresis  and  senile 
dementia  in  their  terminal  stages),  in  which  it  is  asso- 
ciated with  general  intellectual  cnfeeblement.  In  its 
less  severe  forms  indifference  is  manifested  by  disap- 
pearance of  th(^  most  elevated  and  the  most  complex 
sentiments,  with  conservation  and  often  even  exalta- 

74 


SYMPTOMATOLOGY.  75 

tion  of  the  sentiments  of  an  inferior  order.  The  altru- 
istic tendencies  are  the  first  to  become  effaced,  while 
the  egoistic  sentiments  persist.  Only  the  satisfaction 
of  their  material  wants  still  concerns  the  patients  and 
governs  their  activity.  Many  take  no  interest  during 
the  visits  of  relatives  in  anything  excepting  the  eatables 
brought  to  them;  they  eat  as  much  as  they  can,  fill 
their  pockets  with  the  rest,  and  leave  without  taking 
the  trouble  to  express  their  thanks  or  even  to  bid  their 
visitors  good-by. 

Morbid  indifference  may  be  conscious  or  uncon- 
scious. In  the  first  case  it  is  realized  by  the  subject 
as  a  painful  phenomenon.  The  patients  often  say:  "  I 
have  lost  all  feehng,  nothing  excites  me,  nothing  pleases 
me,  nothing  makes  me  sad."  Some  complain  of  being 
unable  to  suffer.  This  state,  which  may  be  called 
painful  psychic  anoesthesia,  is  frequent  at  the  beginning 
of  psychoses  and  sometimes  persists  through  the  entire 
duration  of  the  affection  (affective  melancholia,  de- 
pressed periods  of  recurrent  insanity). 

In  the  second  case,  which  is  more  frequent,  the  dimi- 
nution of  affectivity  is  not  noticed  by  the  patient. 
Such  is  always  the  case  in  states  of  dementia. 

The  changes  of  other  mental  faculties,  such  as  mem- 
ory and  general  intelhgence,  are  not  necessarily  propor- 
tionate to  those  of  affectivity.  Notably  in  dementia 
prsecox  it  is  not  rare  to  find  a  fairly  good  memory  and 
a  relatively  lucid  intelligence  coexisting  with  complete 
indifference. 

Exaggeration  of  affectivity.— Often  combined  with 
indifference,  as  has  been  shown  above,  exaggeration 
of  affectivity  is  encountered  in  most  mental  affections, 


76  MANUAL  OF   PSYCHIATRY. 

congenital  and  acquired.  It  constitutes  the  basis  of 
irritable  and  changeable  moods  and  of  the  extreme 
irascibility  so  often  seen  among  the  insane  and  among 
degenerates  in  general. 

In  the  acquired  psychoses  it  is  an  early  symptom, 
appearing  at  times  long  before  the  other  phenomena. 
An  individual  previously  calm,  gentle,  kind,  becomes 
disagreeable,  ill-natured,  violent.  "  He  is  completely 
changed,"  is  a  remark  often  made  by  the  relatives. 

IrritabiUty  is  almost  always  associated  with  vari- 
abihty  of  moods. 

Disorders  of  affectivity  serve  to  characterize  a  large 
and  important  group  of  patients  included  under  the 
somewhat  vague  designation  of  ''  constitutional  psy- 
chopaths." In  these  individuals  the  emotions  are 
entirely  out  of  proportion  with  their  causes.  The 
death  of  an  animal  plunges  them  into  unlimited  despair, 
the  sight  of  blood  brings  on  syncope,  the  most  simple 
affairs  preoccupy  their  minds  so  as  to  make  them 
lose  their  sleep.  Sensitive  in  the  highest  degree,  they 
see  in  everything  malevolent  intentions,  disguised 
reproaches.  But  their  sentiments,  though  very  intense, 
do  not  last  long;  sorrows,  enthusiasms,  resentments,  are 
with  them  but  a  short  blaze. 

Morbid  depression.  —  Depression  presents  itself  in 
pathological  states,  as  it  does  in  the  normal  state,  in 
two  forms:  active  and  passive.  This  distinction  is 
founded  upon  the  presence  or  absence,  or  rather  upon 
the  intensity,  of  psychical  pain.  While  in  active  de- 
pression psychical  pain  is  very  prominent,  in  passive 
depression  it  is  dull,  vague,  scarcely  appreciable.  In- 
deed, as  Dumas  says,  "  the  element  of  pain  is  not  absent 


SYMPTOMATOLOGY.  77 

in  passive  melancholia;  but  it  is  not  an  acute  and  dis- 
tinct psychical  pain.     It  is  but  vaguely  perceived."  ^ 

Passive  depression. — The  fundamental  features  of  pas- 
sive depression  are  lassitude,  discouragement,  resigna- 
tion. Jt  is  always  associated  with  a  marked  degree  of 
psychic  inhibition,  aboulia,  and  moral  ancesthesia,  and 
may  be  complicated  by  delusions  and  hallucinations. 
It  is  accompanied  by  organic  changes  which  have 
been  extensively  studied  by  physiologists  (Darwin, 
Claude  Bernard,  Lange),  and  to  which  Dumas  has  de- 
voted one  of  the  most  interesting  chapters  in  his  book, 
'^  La  tristesse  et  la  joie.'" 

Depression  is  always  associated  with  a  state  of  per- 
ipheral and  probably  cerebral  vaso-constriction,  in  which 
Lange  believed  he  had  found  the  immediate  cause  of  this 
emotion.  This  vaso-constriction  is  apparent  in  the 
pallor  of  the  skin,  coldness  of  the  extremities,  and  ab- 
sence of  the  peripheral  pulse,  which  are  constant  fea- 
tures of  the  depression  of  melancholia.  The  opinion  of 
Lange  is,  however,  too  exclusive.  ''This  vaso-con- 
striction, which  in  the  peripheral  organs  results  in 
coldness  and  pallor  of  the  tissues,  brings  about  in  the 
brain  a  condition  of  anaemia,  undoubtedly  contributing 
to  the  maintenance  of  the  mental  and  motor  inertia; 
but  it  cannot  be  asserted  positively  that  it  is  the 
only  cause  of  these  phenomena.  Morselli  and  Bordoni- 
Uffreduzzi  have  shown  long  since,  in  fact,  that  the 
phenomena  of  depressed  intellectual  activity  may  ap- 
pear before  the  cerebral  circulatory  changes;  this  leads 
to  the  conclusion  that  depression  begins  with  being  the 

*  La  tristesse  et  la  joie,  p.  29.     Paris,  F.  Alcan. 


78  MANUAL  OF   PSYCHIATRY. 

cause  of  the  circulatory  cliangcs  before  becoming  sub- 
ject to  tlieir  influence."  ^ 

In  the  \ery  rare  cases  in  which,  in  spite  of  the  periph- 
eral ^•aso-constriction,  the  cardiac  impulse  retains  its 
force,  tlie  blood  pressure,  according  to  the  laws  formu- 
lateil  by  Marey,  rises;  this  condition  constitutes  the 
first  type  of  depression,  depression  with  hypertension. 

But  alniost  always  the  heart  participates  in  the  gen- 
eral atony  to  which  the  depression  gives  rise,  so  that  the 
blood  ])ressure  falls  in  spite  of  the  peripheral  vasocon- 
striction: this  constitutes  the  second  type  of  depres- 
sion, depression  with  hypotension  (Dumas). 

The  respiratory  disorders  are  no  less  constant  than  the 
circulatory  ones.  ThT^  respirations  are  shallow,  irregu- 
lar, interrupted  by  deep  sighing.  The  quantity  of  car- 
bon dioxide  excreted  tends  to  diminish . 

The  general  nutrition  is  impaired;  this  results  in  loss 
of  flesh,  which  is  but  slight  if  the  depression  lasts  no 
longer  than  a  few  days,  and  which  persists  as  long  as 
the  affective  phenomenon  itself.  The  weight  does  not 
return  to  the  normal  until  the  depression  disappears, 
i.e.,  until  the  patient  either  recovers  or  becomes  de- 
mented. 

The  appetite  is  diminished,  the  tongue  is  coated,  the 
breath  is  offensive.  The  process  of  digestion  is  accom- 
panied by  discomfort  and  often  by  pain  in  the  epigas- 
trium.    Finally,  there    is    almost    always  constipation. 

The  sluggish  metabolism  shown  by  the  diminished 
elimination  of  carbon  dioxide  is  also  ai)parent  from  the 
fiuantitative  and  riualitative    changes    in    the    urinary 

'  Dumas.     Loc.  cit.,  p.  239. 


SYMPTOMATOLOGY.  79 

excretion.  The  quantity  of  urine  voided  in  twenty- 
four  hours  is  diminished.  The  quantity  of  urea,  as  well 
as  that  of  phosphoric  acid,  is  also  diminished  (Observa- 
tions of  Dumas  and  Serveaux). 

The  toxicity  of  the  urine  in  depression  is  undoubtedly 
of  interest,  but  the  results  so  far  obtained  are  somewhat 
conflicting.  According  to  some  authors  it  is  increased, 
according  to  others,  diminished.  This  subject,  still  in 
a  state  of  confusion,  should  be  excluded  from  the  domain 
of  practical  psychiatry. 

Active  depression.  —  The  special  feature  of  active 
depression  is  the  psychical  pain,  which  is  distinct  and 
sufficiently  intense  to  render  the  subject  subjectively 
conscious  of  it.  The  appearance  of  this  new  phenomenon 
modifies  to  a  certain  extent  the  fundamental  symptoms 
which  have  been  described  in  connection  with  passive 
depression. 

Like  physical  pain,  psychical  pain  tends  to  limit  the 
field  of  consciousness,  to  exclude  other  intellectual 
manifestations,  and  to  become  what  Schiile  has  desig- 
nated by  the  term  pain-idea.  In  certain  cases  the 
disturbance  of  consciousness  which  it  causes  results 
in  marked  disorientation  and  confusion.  These  phe- 
nomena, caused  by  the  pain,  become  less  marked  as  the 
pain  becomes  abated  in  intensity  and  disappear  as  the 
paroxysm  passes  off. 

When  psychical  pain  attains  a  certain  intensity  it 
results  in  anxiety.  This  phenomenon  consists  chiefly  in 
a  feeling  of  oppression  or  constriction,  most  frequently 
localized  in  the  precordial  region,  occasionally  in  the 
epigastrium  or  in  the  throat,  and  more  rarely  in  the 
head.     This  peculiar  feeling  is  always  accompanied  by 


80  MANUAL   OF   PSYCHIATRY. 

certain  somatic  phenomena,  the  most  important  of 
which  are  pallor  of  the  skin,  sometimes  actual  cyano- 
sis, panting  respiration,  general  tremor,  irregular  and 
accelerated  pulse,  and  dilatation  of  the  pupils,  which  is 
often  very  marked. 

Anxiety  is  frequently  seen  in  the  melancholias.  It 
also  occurs  in  cases  of  obsession.  It  may  appear  with- 
out cause  in  certain  psychopaths  (the  paroxysmal 
anxiety  of  Brissaud). 

From  the  standpoint  of  the  reactions,  psychical  pain, 
like  physical  pain,  may  manifest  itself  either  by  a  sort  of 
psychomotor  paralysis,  —  so  that  the  patient  remains 
immovable,  with  a  haggard  expression,  silenced,  so 
to  speak,  by  the  anxiety,  —  or  by  various  phenomena 
of  agitation. 

In  the  latter  case,  the  more  frequent,  the  pain,  an 
active  phenomenon,  brings  about  a  reaction  which  to 
a  certain  extent  overcomes  the  fundamental  psychic 
inhibition  and  manifests  itself  by  two  symptoms  which 
are  frequently  seen  together,  motor  agitation  and 
delusions. 

Acting  as  a  stimulus,  psychical  pain  overcomes  the 
motor  inertia  of  melancholia  and  gives  rise  to  melancholic 
agitation,  which  is  cliaracterized  by  movements  that 
are,  in  the  normal  state,  the  expression  of  violent 
despair.  The  patient  wrings  his  hands,  strikes  his 
head  against  the  wall,  etc.  The  agitation  of  anxiety 
is  essentially  an  expression  of  opposition,  of  resistance. 
The  reactions  are  either  automatic  or  governed  by 
delusions:  movements  of  flight,  refusal  of  food,  attempts 
of  suicide,  etc. 

Suicide  is  one  of  the  most  formidable  consequences  of 


SYMPTOMATOLOGY.  81 

psychical  pain.  Though  most  melanchohacs  have  a 
desire  to  die,  the  aboulia  which  characterizes  the  state  of 
depression  very  seldom  permits  them  to  carry  out  their 
desire.  On  recovering  part  of  their  energy  they  are 
apt  to  make  suicidal  attempts. 

Delusions  are  a  frequent  but  not  a  constant  manifesta- 
tion of  psychical  pain.  They  are  absent  in  certain  cases 
of  melancholia  in  spite  of  the  existence  of  even  very 
painful  depression. 

What  is  the  mechanism  of  the  production  of  delusions 
in  melancholia?  The  most  widely  accepted  opinion  is 
that  of  Griesinger:^  "The  patient  feels  that  he  is  a 
prey  to  sadness ;  but  he  is  usually  not  sad  except  under 
the  influence  of  depressing  causes;  moreover,  accord- 
ing to  the  general  law  of  cause  and  effect,  this  sadness 
must  have  a  ground,  a  cause,  —  and  before  he  asks  him- 
self this  question,  he  already  has  an  answer;  all  kinds 
of  mournful  thoughts  occur  to  him  as  explanations; 
dark  presentiments,  apprehensions,  over  which  he 
broods  and  ponders  until  some  of  these  ideas  become  so 
dominating  and  so  persistent  as  to  fix  themselves  in  his 
mind,  at  least  for  some  time.  For  this  reason  these 
delusions  have  the  character  of  attempts  on  the  part  of 
the  patient  to  explain  to  himself  his  own  state." 

Though  of  great  interest,  this  ingenious  theory  is 
perhaps  somewhat  too  exclusive.  Kraepelin  remarked, 
in  fact,  that  the  delusions  occurring  in  states  of  de- 
pression do  not  always  present  the  character  of  expla- 
nations sought  by  the  patient.  Many  melancholiacs 
instead    of   accepting   the   delusions,    on   the    contrary 

*  Griesinger.  Pathologie  und  Therapie  der  psychischen  Krank- 
heiten. 


82  MANUAL  OF   PSYCHIATRY. 

reject  them,  at  least  in  the  beginning.  Again,  the 
appearance  of  a  delusion  does  not  bring  with  it 
the  relative  calm  which  would  be  expected  if  it  really 
constituted  the  explanation  sought  by  the  patient.  It 
seems,  then,  that  this  interpretation,  ingenious  though  it 
is,  is  rather  superficial.  The  view  of  Dumas  appears  to 
be  nearer  the  truth.  Psychical  pain  provokes  delusions 
because  it  acts  as  a  stimulus,  struggling  against  the 
lassitude,  and  finally  conquering  it.  Thus  there  is  no 
logical  relationship  between  psychical  pain  and  delusions, 
but  rather  a  dynamic  one. 

Morbid  anger. — Pain,  associated  with  a  representation 
of  its  cause,  and  sufficiently  intense  to  overcome  the 
psychic  paralysis  which  is  an  essential  accompaniment 
of  depression,  results  in  anger. 

The  violent  and  disordered  reactions  displayed  in 
anger  have  a  purely  automatic  origin,  and  are  often 
associated  with  disturbance  of  consciousness  and  of 
perception  which  finds  various  expressions  in  popular 
language;  a  man  who  is  a  victim  of  violent  anger  is 
often  said  to  be  "beside  himself,"  he  "forgets  him- 
self." 

Like  all  emotions,  anger  is  accompanied  by  somatic 
changes.  The  principal  ones  are:  increase  of  cardiac 
action  and  elevation  of  arterial  tension;  peripheral  vaso- 
dilatation, chiefly  noticeable  in  the  face,  which  assumes 
a  congested  ai)pearance;  jerky  and  convulsive  respira- 
tory movements;  increase  of  most  of  the  secretions; 
abundant  salivation  (foaming),  more  or  less  jaundice, 
(liarrluea,  polyuria;  soiiietimes  suspension  of  the  milk 
secretion;  arrest  of  the.  menstrual  flow;  more  or  less 
marked  cutaneous  anaesthesia;  general  tremor. 


SYMPTOMATOLOGY.  83 

Anger  may  be  met  with  in  all  psychoses,  excepting 
perhaps  involutional  melancholia.  It  sometimes 
reaches  the  intensity  of  furor,  notably  in  idiots,  epilep- 
tics, and  other  patients  with  profound  disorders  of 
consciousness.  It  is  always  associated  with  morbid 
irritability  and  impulsiveness,  of  which  it  is  but  an 
expression. 

Morbid  joy  or  morbid  euphoria. — This  presents  itself 
in  two  forms:  one,  a  calm  joy,  analogous  to  passive 
depression;  the  other,  an  active,  exuberant  joy,  analo- 
gous to  active  depression. 

The  first  when  of  average  intensity  manifests  itself 
by  a  state  of  satisfaction,  a  vague  sense  of  well-being. 
It  is  encountered  in  general  paresis  and  in  certain  forms 
of  tuberculosis.  The  optimism  and  astonishing  con- 
tentment of  some  consumptives  who  have  reached 
the  last  stage  of  their  illness  are  well-known  phe- 
nomena. 

When  calm  euphoria  reaches  its  highest  development 
it  becomes  ecstasy,  in  which  it  is  not  accompanied  by 
any  motor  reaction.  Such  is  the  case  in  certain  forms 
of  mj^stic  deliria. 

Much  more  frequent  than  this  calm  and  tranquil 
form  of  euphoria,  the  active  form,  noisy,  accompanied 
by  motor  reactions,  is  a  constant  symptom  of  the  so- 
called  expansive  forms  of  psychoses:  general  paresis 
with   excitement,    mania,    certain   toxic   deliria. 

Unlike  depression,  euphoria  permits  of  easy  asso- 
ciation of  ideas  and  quick  motor  reactions.  These 
two  phenomena  do  not  always  indicate  real  psychic 
activity.  In  fact  most  frequently  in  pathologic  euphoria 
the  associations  formed  are  aimless,  independent  of  all 


84  MANUAL  OF   PSYCHIATRY. 

voluntary  intellectual  activity,  and  the  motor  reactions 
bear  the  stamp  of  impulsive  acts  originating  automat- 
ically. 

When  pushed  to  a  certain  degree,  the  apparent 
rapidity  of  association  develops  into  flight  of  ideas 
which  has  already  been  described.^ 

The  asj^ect  of  the  patient  in  euphoria  is  the  direct 
opposite  of  that  in  depression.  The  expression  is 
bright,  smiling,  with  the  head  raised  and  the  body 
upright.  The  speech  is  very  animated  and  accom- 
panied by  numerous  gestures. 

The  concomitant  physical  phenomena  are  in  general 
those  of  joy,  that  is  to  say,  the  reverse  of  those  of 
depression. 

First  come  the  cardio-vascular  and  respiratory  phe- 
nomena: peripheral  (and  probably  cerebral)  vaso-dila- 
tation,  acceleration  of  the  pulse,  increased  force  of 
the  cardiac  impulse,  and  an  elevation  or  a  lowering 
of  the  blood  pressure,  depending  upon  w^hether  the 
increased  heart  action  does  or  does  not  compensate 
for  the  peripheral  vaso-dilatation. 

The  respirations  are  accelerated,  deep  and  regular; 
the  elimination  of  carbon  dioxide  is  increased.  The 
general  nutrition  is  active,  as  is  seen  from  the  patient's 
gain  in  flesh  and  from  the  increase  of  excrementitious 
products  in  the  urine. 

These  different  phenomena,  constant  in  normal  joy 
and  frequent  in  morbid  euphoria,  are  howo^■er  absent 
in  some  cases,  when  other  factors  are  present  which 
counterbalance  the  favorable  influence  of  joy.  Such 
is  the  case  when  there  is  intense  motor  excitement,  which, 

'  See  pp.  01  and  02. 


SYMPTOMATOLOGY.  85 

in  spite  of  the  euphoria,  causes  a  rapid  loss  of  flesh. 
Such  is  the  case  also  when  the  underlying  condition 
is  some  severe  bodily  affection.  The  general  paretic 
or  the  consumptive  with  euphoria  is  none  the  less 
cachectic,  for  in  such  cases  a  generally  flourishing  state 
of  health  is  not  possible. 

Certain  anomalies  are  very  difficult  to  explain.  Some 
maniacs  show,  instead  of  an  acceleration  of  the  pulse 
characteristic  of  states  of  euphoria,  a  slowing  which 
is  at  times  quite  marked.  I  have  observed  in  a  young 
maniacal  girl  with  marked  excitement  less  than  forty- 
five  pulsations  per  minute  for  several  days.  This  phe- 
nomenon has,  I  think,  not  as  yet  been  satisfactorily 
explained. 

§  2.  Disorders  of  the  Reactions. 

The  different  psychic  operations  which  we  have  so 
far  considered  —  perception,  association  of  ideas,  affec- 
tive phenomena  —  find  their  outward  expression  in  the 
reactions.  Like  association  of  ideas,  reactions  may 
be  of  two  kinds :  voluntary  and  automatic. 

Between  a  voluntary  act  accomplished  in  full  self- 
possession  and  a  pun^ly  automatic  act  there  are  all 
intermediate  gradations;  we  pass  from  the  one  to  the 
other  by  a  gradual  insensible  transition.  The  partici- 
pation of  the  conscious  will  diminishes  as  that  of  the 
automatism  becomes  more  prominent,  or  inversely. 

We  have  seen  that  in  normal  ideation  voluntary  and 
conscious  associations  tend  to  inhibit  automatic  asso- 
ciations. Similarly  the  conscious  will  tends  to  inhibit 
automatic  reactions. 


86  MANUAL  OF   PSYCHIATRY. 

We  shall  study:  (1)  aboulia,  or  paralysis  of  voluntary 
reactions;   and  (2)  automatic  reactions. 

Aboulia. — Complete  paralysis  of  the  will  brings  about, 
depending  upon  the  character  of  the  case,  either  stupor 
or  absolute  automatism.  When  less  pronounced  it  is 
manifested  clinically  by  a  general  sense  of  fatigue  and 
discouragement,  by  slowness  and  unsteadiness  of  the 
movements,  and  by  the  painful  effort  that  is  necessary 
for  the  accomplishment  of  all  spontaneous  or  com- 
manded acts.  The  voluntary  apparatus  then  resembles 
a  rusty  mechanism  which  works  only  with  difficulty. 

Like  sluggishness  of  association,  which  in  most  cases 
accompanies  it,  aboulia  is  a  manifestation  of  psychic 
paralysis. 

Automatic  reactions.  — These  may  be  paralyzed  to 
the  same  degree  as  voluntary  reactions  and  give  place 
to  the  absolute  inertia  of  stupor;  or,  on  the  contrary, 
they  may  become  exalted  by  reason  of  the  enfeeblement 
of  the  conscious  will. 

We  distinguish:  (A)  positive  automatic  reactions; 
and  (B)  negative  automatic  reactions. 

(A)  Positive  automatic  reactions  are  expressed  clinic- 
ally by  two  phenomena:  suggestibility  and  impulsive- 
ness. 

By  suggestibility  is  understood  a  state  in  which  the 
reactions  are  compelled  by  external  impressions.  Its 
most  perfect  expression  is  catalepsy,  in  which  the  limbs 
assume  and  retain  the  attitudes  in  which  they  are 
placed  by  the  examiner.  This  phenomenon  has  been 
termed  waxy  flexibility  (flcvibilitas  cerea). 

Many  patients  appear  to  have  lost  all  individual  will 
and  are  reduced  to  pure  automatons.      Some    repeat 


SYMPTOMATOLOGY.  87 

exactly  the  words  (echolalia)  or  the  gestures  (echo- 
praxia)  of  the  persons  around  them.  Others  exhibit  no 
spontaneous  activity,  but  are  able  to  execute  without 
hesitation  any  command.  Such  is  the  case  with  hyp- 
notized subjects,  certain  catatonics,  etc.  Sometimes 
it  suffices  to  start  them  moving,  when  they  will  con- 
tinue and  accomplish  a  series  of  acts  to  which  they  are 
accustomed. 

Suggestibility  is  the  dominant  note  of  the  character  of 
certain  individuals,  mostly  credulous  and  weak-minded, 
whose  thoughts  are  governed  by  external  impressions, 
whose  will  is  nil,  and  who  yield  to  the  domination  of  the 
most  diverse  influences,  good  or  bad.  Many  criminals 
belong  to  this  class. 

Impulsive  reactions  or  impulses  are  to  be  divided  into 
three  groups:  (a)  impulses  of  passion;  (6)  simple  im- 
pulses; (c)   phenomena  of  stereotypy. 

(a)  Impulses  of  passion  always  depend  upon  abnormal 
irritability.  They  are  determined  by  provocation  that 
is  often  insignificant  and  are  accomplished  independ- 
ently of  any  mental  reflection.  They  are  met  with  in 
a  great  many  patients:  constitutional  psychopaths, 
epileptics,  maniacs,  etc.  A  maniac  feels  his  neighbor 
give  him  a  slight  push;  he  immediately  strikes  him 
without  reflecting  that  the  latter  had  no  malevolent 
intention,  that  he  was  perhaps  even  unconscious  of 
having  touched  him,  etc.  This  is  an  impulse  of 
passion. 

(6)  Simple  impulses,  purely  automatic,  appear  with- 
out any  emotional  shock  and  without  a  shadow  of 
provocation.  One  patient  suddenly  threw  into  the 
fire  the  gloves,  hat,  and  handkerchief  of  her  daughter 


88  MANUAL  OF  PSYCHIATRY. 

who  came  to  visit  her  at  the  sanitarium.  Afterwards 
during  a  moment .  of  remission  she  remembered  per- 
fectly the  act  and  the  circumstances  under  which  it  was 
accomplished,  but  was  not  able  to  furnish  any  explana- 
tion for  it. 

The  impulse  may  be  conscious.  A  patient  is  sud- 
denly seized  with  a  strong  desire  to  steal  some  object 
from  a  show-window,  the  possession  of  which  could  be 
neither  useful  nor  pleasant  to  him;  he  does  not  yield 
to  this  impulse,  which  he  recognizes  as  pathological. 
This  is  a  conscious  impulse.  This  phenomenon  is 
closely  allied  to  imperative  idea,  of  which  it  is  but  an 
accentuation. 

(c)  Stereotypy  consists  in  a  morbid  tendency  to 
retain  the  same  attitudes,  or  to  repeat  the  same  words 
or  the  same  movements.  Hence  the  three  kinds  of 
stereo  tjq^y : 

Stereotypy  of  attitudes; 

Stereotypy  of  language:  verbigeration; 

Stereotypy  of  movements. 

Certain  patients  remain  for  hours  at  a  time  in  the 
most  uncomfortable  attitudes;  others  will  walk  a  long 
distance,  taking  alternately  three  steps  forward  and 
two  backward;  still  others  will  repeat  indefinitely  the 
same  phrase  or  the  same  verse. 

(B)  Negative  autojimtism. — This  forms  the  basis  of 
negativism  and  consists  in  the  annulment  of  a  \olun- 
tary  normal  reaction  by  a  pathological  antagonistic  ten- 
dency. 

The  patient  is  requested  to  give  his  hand;  the  volun- 
tary reaction  which  tends  to  appear  and  which  would 
result  in  compliance  with  the  request,  is  arrested,  sup- 


SYMPTOMATOLOGY.  89 

pressed  by  automatic  antagonism.  This  disorder  of  the 
will  has  been  designated  by  Kraepelin,  who  has  made 
an  admirable  study  of  it,  by  the  term  Sperrung,  a 
word  which,  literally  translated  into  English,  means 
blocking.  A  more  significant  term  perhaps  would  be 
psychic  interference.  The  two  antagonistic  tendencies 
neutralize  each  other  hke  interfering  sound-waves  in 
physics. 

On  a  superficial  examination  negativism  may  resem- 
ble aboulia.  These  are,  however,  two  very  different 
phenomena.  While  the  latter,  purely  passive,  is  the 
result  of  persistent  paralysis  against  which  the  patient 
struggles  with  more  or  less  success,  the  former,  an  active 
phenomenon,  depends  not  upon  paralysis  but  upon  a 
perversion  of  the  will.  Negativism  is  often  manifested 
only  in  certain  kinds  of  reactions.  One  patient  who 
walks  about  without  any  effort  does  not  open  his 
mouth.  Another  who  makes  his  toilet,  eats  unassisted, 
and  even  works,  remains  in  complete  mutism,  making 
no  response  in  spite  of  all  perseverance  on  the  part  of 
the  questioner. 

In  a  more  marked  degree  negative  automatism  results 
not  only  in  the  arrest  of  normal  reactions,  but  also  in 
the  production  of  contrary  reactions. 

Thus  if  one  attempts  to  flex  the  patient's  head  he 
extends  it,  and  vice  versa.  If  he  is  requested  to  open 
his  half-shut  eyes  he  closes  them,  and  if  the  examiner 
attempts  to  force  them  open,  his  orbicularis  muscle  con- 
tracts in  a  veritable  spasm.  Wernicke  observed  that 
while  flexibilitas  cerea  chiefly  shows  itself  in  the  hmbs, 
negativism  mostly  affects  the  muscle  groups  of  the  head 
and  neck. 


90  MANUAL  OF   PSYCHIATRY. 


§  3.  Disorders   of  Ccenesthesia  and   of  the 
Personality, 

Disorders  of  ccenesthesia. —  By  ccrnesthesia  or  vital 
sense  is  understood  "the  general  feeling  which  results 
from  the  state  of  the  entire  organism,  from  the  normal 
or  abnormal  progress  of  the  vital  functions,  par- 
ticuarly  of  the  vegetative  functions  "  (Hoffding.)  The 
stimuli  which  produce  this  sense  are  vague  and  poorly 
localized,  and  are  perceived  not  individually  but  together 
as  a  whole. 

The  harmony  which  normally  exists  between  the  di- 
verse organic  functions  produces  a  \'ague  sense  of  satis- 
faction and  of  well-being.  All  causes  tending  to  destroy 
this  harmony  will  produce  in  consciousness  a  feeling  of 
malaise  and  of  suffering  more  or  less  definite  and  more 
or  less  acute.  Thus  the  disorders  of  co^nesthesia  are 
intimately  connected  with  disorders  of  afTectivity;  most 
of  the  depressed  states  have  for  their  basis  an  alteration 
of  the  vital  sense. 

Disorders  of  the  personality.  —  Alterations  of  the  per- 
sonality constitute  the  symptom  which,  following  Wer- 
nicke, we  have  termed  atdo])sychic  disorientation . 

These  disorders  may  be  arranged  in  three  principal 
groups : 

(a)  Weakening  of  the  notion  of  personality; 

(6)  Transformation  of  the  personality; 

(r)    Reduplication  of  the  i)ersonality. 

(a)  The  notion  oj  personality  may  be  incomplete  or 
absent;  it  may  have  never  been  developed  at  all,  or  it 
may  have  been  but  incompletely  developed,  as  in  idiots 


SYMPTOMATOLOGY.  91 

and  imbeciles,  or  it  may  have  disappeared  or  have  be- 
come weakened  under  the  influence  of  a  pathogenic 
cause,  as  in  mental  confusion,  epileptic  delirium,  melan- 
cholic depression  with  stupor,  etc. 

(b)  Transformation  of  the  personality  may  be  complete 
or  incomplete. 

In  the  first  case  the  patients  forget  or  deny  everj'thing 
pertaining  to  their  former  personality.  Thus  one  patient 
claimed  that  she  was  Mary  Stuart,  wanted  to  be  ad- 
dressed as  "Her  Majesty  the  Queen  of  Scotland,"  and 
attired  herself  in  costumes  similar  to  those  of  that  time. 
She  became  furious  when  called  by  her  own  name,  and 
obstinately  refused  to  accept  the  visits  of  her  husband 
and  children,  whom  she  called  "  impostors.  "  Another 
patient,  afflicted  with  hysteria,  believed  herself  to  have 
been  transformed  into  a  dog;  she  barked  and  walked  on 
all  fours.  Still  another  patient  at  the  Salpetriere  re- 
ferred to  herself  as  "  the  person  of  myself.  " 

Complete  transformation  of  the  personality  may  be 
permanent,  constituting,  according  to  the  excellent  ex- 
pression of  Ribot,  a  true  alienation  of  the  personality; 
or  it  may  be  transitory,  so  that  the  new  ego  disappears 
at  a  certain  time  to  be  replaced  again  by  the  former 
ego.  In  cases  in  which  the  normal  personality  and  the 
pathological  one  replace  each  other  mutuaUy  several 
times  we  have  variation  by  alternation. i 

Incomplete  transformation  of  the  personality  exists  in 
a  great  many  cases  in  which  the  patients  are  led  by  their 
delusions  to  attribute  to  themselves  imaginary  talents, 
powers,  or  titles,  without  at  the  same  time  completely 

^  Ribot.      The  Diseases  of  Personality. 


92  MANUAL  OF   PSYCHIATRY. 

abolishing  their  real  ego.  One  patient  suffering  from  a 
chronic  delusional  state  of  old  standing  claimed  that  he 
was  St.  Peter,  and  explained  that  he  had  been  incarnated 
in  an  earthly  man  for  the  purpose  of  bringing  happiness 
to  mankind.  A  general  paretic  claimed  that  he  was 
Emperor  of  Asia,  reigning  in  Pckin,  being  at  the  same 
time  aware  of  the  fact  that  he  was  living  in  Paris,  and 
was  a  newspaper  vender, 

Garnier  and  Dupre  have  described  under  the  name 
of  paroxysmal  mental  puerilism  ^  '*  a  retrogression  of 
the  intellect  to  its  primitive  stages,"  a  state  in  which 
the  subject  once  more  becomes  psychically  a  child,  the 
transformation  being  only  a  temporary  one.  In  the 
observation  which  they  report  a  woman  of  thirty-three 
years  took  pleasure  in  childish  amusements,  such  as  play- 
ing with  dolls,  and  expressed  herself  in  such  childish 
language  that  she  created  the  impression  *'  not  of  an 
adult  woman  of  thirty-three  years,  but  of  a  child  of 
five  years."  This  interesting  syndrome  is  encountered 
in  the  most  diverse  affections.  It  may  be  met  with 
in  hysteria,  in  cerebral  tumors,  in  abscess  of  the 
brain,  etc. 

(c)  Reduplication  of  the  personality  consists  in  the 
devel()))mcnt  of  a  new  personality  of  a  ])arasitic  nature 
alongside  of  the  real  personality  of  the  patient. 

This  redu))lication  is  the  origin  of  the  idea  of  posses- 
sion so  frequent  in  chronic  delusional  melancholia, 
and  results  in  a  psychic  disaggregation  the  most  impor- 
tant manifestations  of  which  are  autochthonous  ideas 

'  Transformation  <le  la  person  nalit/^.  Ptu'rilisme  mental  paroxys- 
tique.     Prosse  medicale,  1901,  No.  101. 


SYMPTOMATOLOGY.  93 

(psychic  hallucinations)  and  motor  hallucinations.  As 
I  have  had  occasion  to  indicate  above,  the  patient,  feel- 
ing that  he  is  losing  control  of  his  own  thoughts  and 
movements,  concludes  that  a  strange  personality  has 
taken  possession  of  him. 


CHAPTER  V. 

THE  PRACTICE  OF  PSYCHIATRY. 
HISTORY   TAKING.  —  METHODS  OF  EXAMINATION. 

The  data  for  diagnosis,  prognosis,  and  treatment 
are  obtained  in  psychiatry,  as  in  other  branches  of 
medicine,  from  the  case  history  and  from  the  direct 
examination  of  the  patient. 

§  1.    History  Taking. 

Information  must  be  sought  from  all  available 
sources  and  the  various  'data  checked  against  each 
other  to  insure  accuracy  as  far  as  possible. 

The  patient  himself,  if  able  and  willing  to  cooperate, 
can  often  furnish  information  that  is  of  the  most  in- 
timate kind  and  not  to  be  had  from  other  informants ; 
this  is  especially  true  in  regard  to  the  sexual  life  and 
venereal  infections.  Besides,  it  is  always  useful  to 
have  a  free  expression  of  the  patient's  viewpoint,  even 
if  the  statements  made  by  him  are  incorrect. 

Further  information  is  to  be  sought  from  the 
patient's  relatives  and  friends  and,  in  a  case  pre- 
senting a  history  of  i)revious  admissions,  from  the 
records  of  the  institutions  in  which  he  was  treated. 

l^fforts  to  secure  a  case  history^  should  not  stop 
here,  as  they  do  too  commonly  in  the  practice  of 
many  institutions.     It  is  now  widely  recognized  that 

94 


THE  PRACTICE  OF  PSYCHIATRY.  95 

a  satisfactory  knowledge  of  the  family  history  and 
of  the  nature  of  the  environment,  in  the  midst  of 
which  the  patient  has  lived  and  developed  his  psy- 
chosis, is  hardly  to  be  had  without  field  investigation, 
affording  opportunities  of  interviewing  relatives, 
friends,  neighbors,  family  physicians,  employers,  and 
others  who  do  not  visit  the  hospital;  consulting 
public  records  of  births,  marriages,  divorces,  and 
deaths;  and  studying  at  first  hand  the  home  con- 
ditions. 

These  considerations,  as  well  as  others  pertaining 
to  social  service  and  after-care  of  paroled  or  dis- 
charged patients,  have  led  to  the  growing  practice 
of  employing  field  workers  in  institutions.  The  Eu- 
genics Record  Office,  Cold  Spring  Harbor,  N.  Y., 
The  New  York  School  of  Philanthropy,  and  several 
universities  now  offer  extension  courses  to  meet  the 
demand  for  trained  persons  for  such  positions. 

Family  history.^  —  A  full  family  history  in  a  given 
case  may  be  of  value  not  only  for  a  study  of  its 
etiology  but  also  for  the  assistance  that  is  at  times  to 
be  derived  from  it  in  the  interpretation  of  clinical 
manifestations. 

The  questioning  should  be  systematic,  taking  up 
members  of  the  family  individually,  and  covering 
wherever  possible  at  least  the  patient's  children, 
brothers  and  sisters,  nephews  and  nieces,  parents, 
and  grandparents,  uncles,  aunts,  and  cousins  on 
both  the  paternal  and  maternal  sides. 

1  C.  B.  Davenport,  in  collaboration  with  others.  The  Family 
History  Book.  Bulletin  No.  7.  Eugenics  Record  Office,  Cold 
Spring  Harbor,  N.  Y.,  1912. 


96  MANUAL  OF  PSYCHIATRY. 

For  each  member  of  the  family  it  is  desirable  to 
place  on  record  the  name,  sex,  birthplace,  age  (or 
age  at  time  of  death),  cause  of  death,  education,  oc- 
cupation, and  marital  condition. 

As  special  subjects  of  inquiry  may  be  mentioned 
the  following:  insanity,  a  description  to  be  secured 
in  each  case  of  time  and  manner  of  onset,  principal 
manifestations,  course,  termination,  and  recurrencies; 
epilepsy  and  other  disorders  which  seem  to  be 
related  to  it,  namely,  convulsions  in  childhood,  faint- 
ing spells,  migraine,  and  periodic  dipsomania;  ar- 
rests of  development,  as  shown  by  delayed  walking 
and  talking  not  due  to  physical  causes,  poor  record 
at  school,  lack  of  success  in  work;  suicide,  method 
and  immediate  cause  to  be  given  if  known;  the 
milder  psychoses,  hysteria,  neurasthenia,  psychas- 
thenia,  "nervous  prostration";  addictions  to  alco- 
hol or  drugs,  details  to  be  given  of  amounts  and 
frequency  of  indulgence,  periods  of  abstinence,  etc.; 
anti-social  traits,  criminality,  mendacity,  prostitution, 
vagrancy,  pauperism  not  dependent  on  physical 
causes;  temperamental  anomalies,  such  as  undue 
irritability,  spells  of  ''the  blues,"  worrisome  or  h>"po- 
chondriacal  disposition,  excessive  religious  preoccu- 
pation, miserliness,  and  other  eccentricities;  sexual 
anomalies,  especially  perv^ersions  and  inversions; 
and  finally  conditions  like  asthma,  sick  headaches,  and 
recurrent  vomitirig,  the  relation  of  which,  if  there  be 
any,  to  the  neuropathic  states,  is  not  clearly  estab- 
lished. 

The  fact  of  a  sojourn  for  treatment  or  custody  in 
a  hospital,  sanatorium,  asylum,  colony  for  the  epi- 


THE   PRACTICE  OF  PSYCHIATRY.  97 

leptic  or  feeble-minded,  or  almshouse,  or  of  im- 
prisonment in  a  penal  institution,  should  be  recorded 
wherever  ascertained  with  dates  and  other  details. 

In  connection  with  cases  of  Huntington's  chorea 
only  similar  heredity  seems  to  be  of  significance; 
hence  inquiry  should  be  especially  directed  to  other 
cases  of  chorea  in  the  family. 

In  cases  like  juvenile  paresis  the  question' of  con- 
genital syphilis  may  arise,  which  the  family  history 
should,  of  course,  help  to  clear  up. 

It  is  not  enough  to  state  in  each  case  merely  the 
alleged  fact  of  the  existence  of  one  or  more  of  the 
above-mentioned  conditions ;  but  wherever  anything 
of  the  sort  is  found  a  description  in  terms  of  the 
conduct  and  life  course  of  the  individual  should  be 
given,  sufficient  to  establish  the  fact  as  alleged. 

Personal  history.  —  Here  the  main  topics  of  in- 
quiry are:  (a)  Were  there  any  conditions  during 
intra-uterine  life  (infections,  eclampsia  traumatisms 
of  the  mother;  hydrocephalus  or  other  diseases  of 
the  foetus),  at  birth  (premature  labor,  difficult  or  in- 
strumental delivery  with  resulting  head  injury),  or 
in  infancy  or  childhood  (meningitis,  whooping  cough 
with  intracranial  complications),  likely  to  interfere 
with  the  mental  development?  (5)  Were  there  at 
any  time  prior  to  the  onset  of  the  mental  disorder  any 
abnormalities  in  the  patient's  constitutional  make-up? 
Convulsions  in  infancy,  childhood,  or  later;  fainting 
spells;  delayed  walking  or  talking;  poor  record  at 
school,  lack  of  success  in  work;  anti-social  traits 
(criminality,  mendacity,  prostitution,  vagrancy); 
temperamental  anomalies  (undue  irritability,  spells 


98  MANUAL  OF  PSYCHIATRY. 

of  "the  blues,"  worrisome  or  hypochondriacal  dis- 
position, seclusiveness,  excessive  religious  preoccu- 
pation, miserliness,  or  other  eccentricities) ;  and 
sexual  anomalies  (masturbation,  perversions,  inver- 
sions).^ (c)  What  were  the  patients  habits  in  regard 
to  the  use  of  alcohol?  What  has  led  to  its  use? 
(Domestic  infelicity,  being  out  of  work,  business  re- 
verses, sociability.)  Was  its  use  regular  (daily, 
week  ends)  or  only  occasional?  What  were  the 
beverages  used?  (Beer,  wine,  whiskey.)  In  what 
quantities  were  they  used?  Did  he  go  on  sprees? 
Did  he  become  intoxicated,  if  so,  how  often?  Did 
the  drinking  affect  the  patient's  appetite  or  health 
in  any  way?  Did  it  cause  him  to  lose  time  from  his 
regular  occupation?  A  particularly  detailed  account 
should  be  obtained  for  the  time  immediately 
preceding  the  onset  of  the  psychosis,  (d)  Detailed 
information  should  be  sought  concerning  venereal 
infections,  particularly  syphilis;  date  and  source  of 
infection,  manifestations;  was  treatment  prompt?  of 
what  did  it  consist?  was  it  thorough?  was  it  sys- 
tematic, prolonged,  and  serologically  controlled?  did 
the  serological  tests  ultimately  become  and  remain 
negative?  (e)  Did  the  patient  ever  suffer  a  head  in- 
jury? Did  he  become  unconscious  either  immedi- 
ately following  the  injury  or  after  an  interval?  How 
long  did  the  unconsciousness  last?  What  sjTnptoms 
were  observed  after  recovery  of  consciousness?  Was 
there  a  fracture  of  the  skull?     Was  the  patient  oper- 


1  Auf^iiist  Iloch  and  G.  S.  Anisdcn.  A  Guide  to  the  Descriptive 
Study  of  the.  I\rsonalilij.  N.  Y.  State  Hosp.  Bulletin,  N.  S.,  Vol.  VI., 
1913,  p.  314. 


THE  PRACTICE  OF  PSYCHIATRY.  99 

ated  on?  Did  he  eventually  recover  fully  from  the 
effects  of  the  injury?  (/)  Obtam  a  description  of  the 
patient's  bringing  up,  his  sexual,  domestic,  marital, 
and  business  life  with  a  view  to  determining  whether 
there  were  any  other  pathogenic  influences  such  as 
have  already  been  mentioned  in  the  chapter  on 
Etiology  under  the  heading  of  incidental  or  contrib' 
uting  causes. 

History  of  psychosis.  —  Were  there  any  ^previous 
attacks  of  mental  trouble?  What  were  the  cause, 
date  and  mode  of  onset,  principal  manifestations, 
course,  duration,  and  outcome  of  each?  What  was 
the  immediate  cause  of  the  present  attack?  The 
date  of  its  onset  and  the  manner,  i.e.,  whether  sud- 
den or  gradual?  Earliest  observed  manifestations? 
Principal  features?  What,  if  any,  was  the  treatment 
of  the  attack  prior  to  the  patient's  admission  to  the 
hospital?     What  led  to  the  patient's  commitment? 

In  cases  of  constitutional  psychoses  a  neuro- 
pathic family  history  and  evidence  of  abnormal 
make-up  are  now  generally  accepted  as  accounting, 
in  a  measure,  merely  for  the  fact  that  a  psychosis 
has  occurred,  but  not  as  explaining  why  it  occurred 
at  the  particular  time  when  it  did,  nor  its  special 
content  and  other  manifestations.  A  case  history 
is  imperfect  which  fails  to  connect  specific  environ- 
mental happenings  ^\dth  the  development  of  symp- 
toms, both  chronologically  and  by  content.  It  will 
be  granted,  of  course,  that  in  many  cases,  owing  to 
a  symbolic  nature  of  the  trends  or  reactions,  the 
etiological  mechanism  is  veiled;  but  this  should  not 
prevent  an  attempt,  at  least,  to  seek  out  the  con- 


100  MANUAL  OF  PSYCHIATRY. 

nections  which,  it  must  be  assumed,  exist  in  every 
case. 

§  2.   Methods  of  Examination. 

Physical  examination.  —  Height,  weight  (com- 
pared with  usual  weight),  malformations  (especially 
of  skull),  general  state  of  nutrition,  pallor  (haemo- 
globin estimation  and  cell  count,  if  indicated),  tem- 
perature, pulse,  respiration,  appetite,  condition  of  the 
bowels,  sleep,  menstrual  function;  subjective  com- 
plaints (vertigo,  headache,  pains,  weakness);  cya- 
nosis, dropsy,  jaundice,  eruptions;  scars  or  other 
evidences  of  old  or  recent  injury.  Heart,  lungs, 
abdominal  organs,  urine;  vaginal  examination; 
blood  pressure.  Nervous  system:  smell,  hearing, 
taste,  cutaneous  sensibility;  vision,  errors  of  refrac- 
tion, hemianopsia,  ophthalmoscopy  if  indicated; 
nystagmus,  strabismus ;  pupils,  —  equal  or  unequal, 
regular  or  irregular  in  outline,  reaction  to  light 
normal  or  sluggish  or  slight  in  excursion,  reaction  to 
distance;  innervation  oi  facial  muscles, — equal  or 
asymmetrical ;  grips  in  the  two  hands,  —  equal  or 
unequal  (dynamometer  test) ;  strength  of  legs  (for 
test  of  weakness  of  one  lower  extremity  have  both 
lower  extremities  raised  and  held;  the  weaker  limb 
will  sink  before  the  other);  coordination,  —  writing, 
buttoning  coat,  gait,  Romberg  sign,  balancing  power 
on  either  foot;  reflexes,  —  knee  jerks,  with  and  with- 
out Jendrassic  reinforcement  (normal,  unequal,  ex- 
aggerated, diminished,  lost),  ankle  clonus,  plantar 
reflex  (Babinski  sign),  sphincter  control;  tremors,  — 
eyelids,  lips,  tongue,  hands,  —  fine,  coarse,  intention 


THE  PRACTICE  OF  PSYCHIATRY.  101 

(handwriting);  choreiform  or  athetoid  movements; 
speech,  —  stuttering,  slurring,  scanning  (test  phrases : 
third  riding  artillery  brigade,  particular  popularity, 
Methodist  Episcopal);  aphasia  (systematic  exami- 
nation if  indicated) ;  convulsions,  —  frequency,  loss 
Or  preservation  of  consciousness,  localized  or  general, 
with  or  without  aura,  biting  of  tongue,  voiding  of 
urine,  followed  by  stupor  or  prompt  recovery. 

Mental  examination.^  —  Much  of  value  can  be 
learned  on  a  patient's  being  brought  to  an  institution 
from  his  general  appearance,  manner,  and  spontaneous 
utterances:  his  appearance  may  be  disheveled,  neg- 
lected, untidy;  he  may  seem  dejected,  or  irritable, 
or  happy,  or  apathetic;  he  may  cooperate  in  the 
hospital  routine  showing  a  more  or  less  intelligent 
adaptation;  or  merely  submit  in  a  passive  way  to 
being  undressed,  bathed,  etc.,  by  the  attendants;  or 
he  may  be  resistive  and  violent ;  he  may  be  taciturn 
or  even  mute,  failing  to  respond  to  any  question,  or 
he  may  be  talkative,  protesting,  or  complaining,  or 
wailing,  or  merely  commenting  on  things  about  him, 
perhaps  showing  disturbances  in  the  flow  of  thought 
like  distractibility,  flight  of  ideas,  incoherence,  ver- 
bigeration. 

The  manner  of  the  clinical  examination  proper 
will  depend  to  a  considerable  extent  on  the  nature 
of  the  case  and  the  amount  of  cooperation.  In  an 
irresponsive,  seemingly  stuporous  case,  or  in  one  pre- 
senting great  excitement  a  complete  mental  exami- 

1  Sommer.  Diagnostik  der  Geisteskrankheiten.  Berlin  and 
Vienna,  1901.  —  Fuhrmann.  Diagnostik  und  Prognodik  der  Geistes- 
krankheiten.    Leipsic,  1903. 


102  MANUAL  OF  PSYCHIATRY. 

nation  is  out  of  the  question  for  the  time  being  and 
can  be  attempted  only  after  subsidence  of  the  hyper- 
acute phenomena.  It  should  be  borne  in  mind,  how- 
ever, that  a  condition  of  seeming  stupor  may  prove 
to  be  either  one  of  marked  depression  or  of  catatonic 
negativism  with  well-preserved  lucidity.  A  detailed 
record  should  be  made  of  the  condition  found, 
especially  of  any  unexplained  peculiarities  in  atti- 
tude or  conduct,  to  be  discussed  with  the  patient 
when  better  cooperation  is  to  be  had. 

In  cases  offering  reasonable  cooperation  it  is  of 
gre^t  advantage  to  proceed  systematically.  Some 
patients  volunteer  to  tell  their  story  as  soon  as  they 
are  brought  into  the  examining  room,  which  they 
should  be,  of  course,  encouraged  to  do;  others  will 
speak  only  when  questioned,  and  then  but  briefly. 
In  any  case  it  is  desirable,  before  actual  testing  is 
begun  or  any  specific  questioning  concerning  hallu- 
cinations or  delusions,  to  get  the  patient's  account 
of  his  trouble  or  at  least  of  the  situation  which  led  to 
his  commitment.  Should  he  show,  in  the  course  of 
his  account,  a  tendency  to  ramble  from  his  subject, 
or  any  disconnectedness,  or  other  disturbance  of  the 
flow  of  thought,  then  it  is  very  useful  to  make  an 
exact  stenographic  record  of  a  sample  of  his  utter- 
ances to  the  extent,  say,  of  half  a  page  or  a  page;  that 
being  done  he  may  be  assisted  by  the  examiner  by 
})eing  interrupted  whenever  necessary  and  reminded 
of  the  points  on  which  he  was  asked  to  give  informa- 
tion. 

It  is  verj'^  important  to  have  the  patient  at  his 
ease  as  far  as  possible,  not  to  arouse  his  antagonism 


THE  PRACTICE  OF  PSYCHIATRY.  103 

or  suspicion  or  apprehension.  The  only  correct  way 
of  approaching  him  is  with  perfect  candor,  without 
indeed  letting  him  think  that  it  is  assumed  that  he 
is  insane,  but  making  him  understand  that  such  has 
been  alleged  to  be  the  case  and  that  it  is  the  ex- 
aminer's business  as  a  physician  to  investigate  his 
case  in  order  either  to  establish  or  disprove  the 
allegation. 

Thus  one  may  begin  with  such  questions  as,  Tell 
me  about  your  case;  have  you  been  sick?  Did  you 
have  any  trouble  at  home?  Why  have  they  brought 
you  here?     Have  you  been  ill-treated? 

As  the  next  step  the  patient  may  be  questioned 
about  the  statements  in  the  commitment  paper  made 
to  show  insanity  and  necessity  of  commitment,  and 
from  that  it  is  easy  to  pass  to  direct  questions  con- 
cerning hallucinations  or  delusions,  following  the 
leads  made  available  by  his  account:  Have  you 
heard  voices?  Has  anyone  hypnotized  you?  Do 
people  talk  about  you?  Do  they  read  your  mind? 
Have  you  been  poisoned?  Are  you  followed  by  de- 
tectives?    Is  it  true  that  you  are  very  wealthy? 

It  goes  without  saying  that  any  hallucinations  or 
delusions  that  may  be  elicited  should  be  gone  into 
thoroughly:  Do  you  hear  the  voices  all  the  time  or 
only  occasionally?  Are  they  distinct?  Are  they 
voices  of  men  or  of  women?  Familiar  or  strange? 
Where  do  they  come  from?  Transmitted  by  some 
apparatus?  What  do  they  say?  What  do  you  do 
when  you  hear  them?  Do  others  hear  them  also  or 
only  you?  Don't  you  think  it  is  just  imagination? 
Or,  What  makes  you  think  you  are  being  poisoned? 


104  MANUAL  OF  PSYCHIATRY. 

Did  you  taste  it  in  your  food?  Have  you  noticed 
any  ill  effects?  Who  is  doing  it?  For  what  reason? 
For  what  object?  What  do  you  plan  to  do  about  it? 
At  this  stage  of  the  interview  the  examiner  will 
probably  already  have  gained  some  idea  of  the 
patient's  orientation,  memory,  education,  and  men- 
tal capacity.  But  it  is  preferable  to  test  these 
specially  and  by  a  uniform  technique  for  all  cases  in 
order  to  obtain  data  for  comparison.  The  following 
questions  are  recommended: 

What  is  your  name? 

Where  were  you  born? 

In  what  year  were  you  bom? 

WTiat  year  is  this? 

How  old  does  that  make  j'ou? 

What  is  your  occupation? 

Where  do  you  live? 

What  is  the  name  of  this  town  or  city? 

How  far  is  it  from  New  York  (or  other  notable  city)? 

Wliat  kind  of  an  institution  is  this? 

What  date  is  to-day?     What  month?     What  day  of  the  week? 

Is  this  morning  or  afternoon? 

\Miere  did  you  come  from?     When? 

How  did  you  come  (train,  boat,  trolley,  carriage,  walk)? 

Did  you  come  alone  or  with  somebody? 

WTiat  did  j-ou  have  for  breakfast  this  morning? 

WTiere  were  j'ou  yesterday? 

\Miere  were  you  a  wec^k  ago? 

Where  were  you  last  Christmas? 

Where  did  you  go  to  school?     Can  you  name  some  of  your 

teachers? 
\Micn  did  you  leave  school? 
When  did  you  begin  work? 
\Mio  was  yoiir  first  employer? 
Count  backwards  from  20  to  1. 

5  +  4?     9  +  7?     26  +  39?     4x8?     5  X  12?     9  X  17? 
Give  the  months  of  the  year. 
Name  five  large  cities  in  the  United  States. 


THE   PRACTICE   OF   PSYCHIATRY.  105 

Where  is  London?     Paris?     Berlin?     Vienna?     Rome? 

Who  is  the  President  of  the  United  States?     Who  was  the  first 

President?     What  war  took  place  while  Abraham  Lincoln 

was  President? 

Retention  may  be  tested  by  giving  the  patient  a 
number,  or  a  name,  or  a  phrase  to  remember  (1473, 
physician's  name,  238  Main  Street),  and  asking  him 
to  recall  it  at  the  end  of  five  minutes. 

At  some  convenient  time  during  the  examination 
an  attempt  should  be  made  to  determine  the  degree 
of  insight  which  the  patient  has  in  regard  to  the 
abnormal  nature  of  his  symptoms.  It  happens  very 
seldom  that  a  patient  admits  that  he  is  insane,  but 
this  is  hardly  a  proper  criterion  of  insight;  in  fact 
where  it  does  happen  it  is  more  apt  to  be  dependent 
on  a  certain  shallowness  of  personality  and  emotion 
than  on  a  real  preservation  of  auto-critical  faculty. 
Thus  one  imbecile  was  asked,  Why  did  they  send  you 
here?  —  ''They  said  I  was  crazy,"  he  answered.  Was 
that  really  so?  he  was  asked  again.  —  "I  guess  so," 
he  said,  grinning  all  the  time.  —  What  is  of  impor- 
tance in  this  connection  is  to  gain  a  precise  idea  to 
what  extent  the  patient  realizes  the  unusualness  of 
his  morbid  experiences  and  behavior  and  their  de- 
pendence, not  necessarily  on  insanity,  but  on  being 
"nervous,"  or  "upset,"  or  on  "overwork,"  or  "lack 
of  sleep,"  or  "drinking  too  much,"  etc. 

Tests  of  reading  and  writing  are  also  very  useful. 

The  first  consists  in  requesting  the  patient  to  read 
aloud  some  paragraph  in  a  book  or  in  a  newspaper 
and  then  having  him  give  an  account  of  what  he 
has  read;  his  account  is  more  or  less  accurate  and 


106  MANUAL  OF  PSYCHIATRY. 

complete.  This  test  may  demonstrate  any  existing 
disorders  of  (1)  perception;  (2)  attention  and  associa- 
tion of  ideas;  (3)  power  of  fixation;  (4)  speech  (phy- 
sical impediments). 

A  systematic  study  of  the  writings  of  the  insane  is 
of  the  highest  interest.  The  symptoms  which  such 
writings  reveal  are  sometimes  so  clear  as  to  be  suf- 
ficient in  themselves  to  characterize  an  affection,  and 
in  all  cases  they  constitute  valuable  elements  of 
diagnosis.  Joffroy  has  very  properly  classified  them 
into  calligraphic  and  psychographic  disorders.  The 
former  pertain  to  the  handwriting  as  such,  which 
may  be  more  or  less  irregular,  tremulous,  hesitating, 
etc.  The  latter  pertain  to  the  content  of  the  writing 
and  reveal  psychic  abnormalities:  weakening  of  at- 
tention (omission  of  words,  syllables,  or  letters,  errors 
of  spelling  due  to  inattention) ,  weakening  of  memory 
(errors  of  spelling  due  to  effacement  of  word  images 
or  to  forgetting  the  rules  of  grammar),  mental  au- 
tomatism (flight  of  ideas,  incoherence,  stereotyped 
repetition  of  letters,  words,  or  phrases),  and  various 
delusions. 

The  writings  constitute  trustworthy,  permanent 
documents  which  may  be  indefinitely  preserved  as 
evidence  of  the  state  of  psychic  (sometimes  also  of 
motor)  functions  of  a  subject  at  a  given  time.  One 
may  also,  with  the  aid  of  the  data  of  graphic  pathol- 
ogy and  solely  by  means  of  examining  the  writings  of 
a  subject,  follow  in  a  certain  measure  the  course  of  a 
mental  disease  the  development  of  which  is  either 
progressive,  as  general  paresis,  or  cyclic,  as  circular 
insanity. 


THE  PRACTICE  OF   PSYCHIATRY.  107 

From  the  standpoint  of  symptomatology  four  kinds 
of  writings  may  be  distinguished :  spontaneous  writ- 
ings, writings  from  copy,  writings  from  dictation,  and 
painstaking  penmanship.  Each  has  its  special  in- 
terest, as  each  enables  us  to  study  particular  types 
of  pathological  phenomena.  Spontaneous  writings 
reveal  chiefly  the  delusions  of  the  subjects  and  are 
often  of  great  value  in  cases  of  dissimulation.  Writ- 
ing from  copy  reveals  chiefly  disorders  of  attention, 
and  writing  from  dictation  reveals  disorders  of 
memory.  Finally,  painstaking  penmanship,  which 
results  from  the  subject's  effort  to  produce  the  best 
possible  handwriting,  brings  out  motor  disorders 
(tremor  and  ataxia). 

Unfortunately  the  study  of  graphic  pathology  in 
order  to  be  fruitful  must  go  into  certain  details 
which  could  not  be  entered  upon  here  for  want  of 
space.  We  must  therefore  limit  ourselves  to  this 
brief  discussion  and  refer  the  reader  to  works  in 
which  this  question  is  specially  treated.^ 

Having  completed  the  examination  it  will  be  found 
very  advantageous  to  prepare  a  summary  of  the 
findings  which  are  of  significance  for  diagnosis,  prog- 
nosis, and  treatment. 

Many  attempts  have  been  made  to  simplify  and. 
standardize  for  institutions  the  work  of  clinical  ex- 

^  Seglas.  Les  troubles  du  langage  chez  les  alienes.  Bibliotheque 
Charcot-Debove.  — •  Koster.  Die  Schrift  bei  Geisteskrankheiten. 
Leipzig,  1902.  —  Joffroy.  Les  troubles  de  la  lecture,  de  la  parole,  et 
de  I'ecriture  chez  les  -paralytiques  generaux.  Nouv.  Iconogr.  de  la 
Salpet.,  Nov.-Dec,  1903.  —  J.  Rogues  de  Fursac.  Les  ecrits  et  les 
dessins  dans  les  maladies  nerveuses  et  mentales.  Paris,  Masson, 
1905. 


108  MANUAL  OF  PSYCHIATRY 

aminations  by  the  use  of  printed  blank  forms.  Ex- 
perience has  shown  that  to  rely  entirely  on  records 
thus  prepared  is  not  consistent  with  good  clinical 
work.  For  a  part  of  the  records,  however,  it  will  be 
found  helpful  to  have  a  statistical  data  sheet  or  card 
such  as  is  used  in  the  New  York  state  hospital  service, 
somewhat  like  the  following: 

Pationt's  name  in  full Admission  No  .  . . 

Date  of  admission 191       Race Sex .... 

Residence Date  of  birth 

Marital  condition  (single,  married,  widowed,  divorced,  separated). 
Occupation  (or  that  of  husband,  father,  or  other  person  on  whom 

patient  is  dependent) Citizenship  (American, 

foreign). 

Nativity  (state  or  country) How  long  in  U.  S 

Nativity  of  father of  mother 

Education  (none,  reads  only,  reads  and  writes,  common  school,  high 

school,  collegiate,  professional).     Religion  (denomination) 

Previous  hospital  residences  (dates  and  duration  of  each) 

Heredity 

Constitutional  make-up  (intellectually  and  temperamentally) 


Alcoholic  habits 

Venereal  history 

Other  etiological  factors 

Date  and  manner  of  onset  of  psychosis 

Diagnosis Legal     status     (committed,     voluntary) 

Permission  for  autopsy  in  event  of  death 

Names  and  addresses  of  relatives,  friends,  or  legal  guardians 


CHAPTER  VI. 

THE   PRACTICE   OF   PSYCHIATRY   {Continued). 

SPECIAL  DIAGNOSTIC  PROCEDURES.  ~  LUMBAR  PUNC- 
TURE. —  WASSERMANN  REACTION.  —  CHEMICAL 
TESTS.  —  BINET-SIMON  TESTS.— EXAMINATION  FOB 
APHASIA.  —  ASSOCIATION  TESTS.  — OTHER  TESTS. 

It  is  not  to  be  supposed  that  the  case  history  and 
the  chnical  examination,  obtained  by  the  methods 
outlined  in  the  preceding  chapter,  will  complete 
the  investigation  of  every  case.  Very  often  these 
methods  afford  but  leads  for  further  investigation 
by  special  methods  according  to  the  indications  pre- 
senting themselves  in  the  case  under  consideration. 
A  suspicion  of  syphilis,  for  instance,  can  by  no  means 
be  definitely  dismissed  by  a  denial  made  either  by 
the  patient  or  other  informants;  the  differentiation 
between  certain  alcoholic  psychoses,  neurasthenia, 
arteriosclerotic  dementia,  and  other  condition,  on 
the  one  hand,  and  general  paresis,  on  the  other, 
cannot  always  be  made  with  certainty  without  the 
aid  of  special  diagnostic  procedures;  the  intellectual 
make-up  of  a  patient  cannot  be  determined  with 
any  degree  of  accuracy  without  resort  to  measure- 
ment by  means  of  the  Binet-Simon  or  other  appro- 
priate psychological  tests. 

^  109 


110  MANUAL  OF  PSYCHIATRY. 

§  1.    Lumbar  Puncture. 

Lumbar  puncture  is  a  simple  and  harmless  pro- 
cedure. The  only  danger,  that  of  infection,  can  be 
entirely  avoided  by  the  exercise  of  ordinary  pre- 
cautions of  asepsis. 

It  is,  however,  contraindicted  in  cases  of  great 
general  weakness  and  in  those  in  which  there  is  evi- 
dence of  abnormally  high  intracranial  pressure 
(brain  tumor).  In  such  cases  lumbar  puncture 
should  not  be  performed,  as  there  is  possibility  of 
fatal  issue.^ 

The  technique  of  obtaining  and  examining  a  speci- 
men of  cerebro-spinal  fluid  is  as  follows: 

The  patient  is  placed  on  a  convenient  table,  lying 
on  the  side,  with  the  back  arched  as  much  as  possible 
and  with  the  knees  drawn  up  so  that  they  almost 
touch  the  chin;  in  this  position  the  spaces  between 
the  laminae  of  the  lower  lumbar  vertebra3  are  as  wide 
as  they  can  be  made.  If  the  patient  is  so  resistive 
that  he  cannot  be  made  to  assume  and  retain  this 
position  the  attempt  might  best  be  postponed  until 
he  is  more  tractable. 

The  back  is  then  scrubbed  with  soap  and  water 
and  washed  with  alcohol,  ether, and  1-2000  bichloride, 
as  for  any  operation.  The  operator's  hands  are, 
of  course,  also  properly  sterilized.  No  anaesthetic, 
general  or  local,  is  required,  as  the  pain  caused  by  the 
puncture  is  scarcely  greater  than  that  which  would 
be  caused  by  a  cocaine  injection. 


'  See   Minet  and  Lavoit.     La  mort  suite  de  punction  lombaire. 
L'ficho  Medical  du  Nord,  Apr.  25,  1909. 


THE  PRACTICE  OF  PSYCHIATRY.  Ill 

A  sterilized  hollow  needle,  about  four  and  a  half 
inches  long,  is  then  introduced  straight,  that  is  to 
say,  without  any  vertical  or  lateral  inclination,  into 
the  space  between  the  laminse  of  the  fourth  and  fifth 
lumbar  vertebrae;  if  more  convenient,  the  space 
above  or  the  one  below  may  be  selected.  The  usual 
guide  for  the  intervertebral  space  is  the  level  of  the 
iliac  crests.  The  point  at  which  the  needle  should 
be  introduced  is  a  trifle  below  and  a  quarter  of  an 
inch  to  one  side  of  the  tip  of  the  vertebral  spine. 
Extending  from  the  level  of  the  upper  border  of  the 
second  lumbar  vertebra  to  that  of  the  sacrum  is  a 
large  meningeal  reservoir  which  is  easily  reached  in 
the  manner  described  above.  In  this  reservoir  are 
contained  the  fibers  of  the  cauda  equina,  which  are 
in  no  danger  of  being  injured  by  the  point  of  the 
needle. 

If  the  needle  strikes  bone  no  attempt  should  be 
made  to  alter  its  direction  by  partly  withdrawing  it 
and  inclining  it  one  way  or  another,  as  it  soon  be- 
comes filled  with  blood  and  the  cerebro-spinal  fluid, 
if  thus  obtained,  will  be  contaminated.  The  needle 
must  be  withdrawn,  cleansed  of  all  blood,  and  re- 
introduced at  another  point.  It  is  best,  perhaps,  to 
have  two  or  three  needles  at  hand  whenever  lumbar 
puncture  is  undertaken. 

As  soon  as  the  point  of  the  needle  has  entered  the 
meningeal  reservoir  cerebro-spinal  fluid  begins  to 
escape  from  its  outer  opening  cither  in  drops  or  in  a 
stream,  depending  upon  the  degree  of  intracranial 
and  intra-spmal  pressure. 

Sometimes,  as  the  needle  passes  through  the  skin 


112  MANUAL  OF  PSYCHIATRY. 

and  subcutaneous  tissues,  especially  when  the  point 
is  not  very  sharp,  the  lumen  becomes  clogged  so  that 
the  flow  of  fluid  is  partly  or  completely  interfered 
with.  The  obstruction  is  readily  removed  by  pass- 
ing a  wire  stylet  through  the  needle. 

About  7  or  8  c.c.  of  the  fluid  is  collected  in  a  test 
tube.  If  too  much  fluid  is  removed  the  patient  is 
apt  to  develop  severe  headaches,  attacks  of  syncope, 
and  vomiting,  which  may  persist  for  two  or  three 
days.  In  any  event  the  patient  should  be  kept  in 
bed  for  two  days  after  the  operation. 

The  fluid  should  be  examined  as  soon  as  possible 
after  it  has  been  obtained,  preferably  within  an  hour, 
as  standing  produces  changes  affecting  especially  the 
cellular  elements. 

Perhaps  of  greatest  help  in  diagnosis  is  the  cell 
count,  for  which  one  has  to  have  (1)  a  Thoma-Zeiss 
mixing  pipette  like  that  used  for  making  white  blood 
corpuscle  counts,  (2)  a  Fuchs-Rosenthal  counting 
chamber,  ruled  as  shown  in  the  accompanying  illus- 
tration, (3)  a  clinical  microscope,  and  (4)  the  follow- 
ing staining  solution: 

Methyl  violet 0.1  gm. 

Distilled  water 50.0  c.c. 

Glacial  acetic  acid 2.0  c.c. 

This  staining  solution  is  drawn  into  the  i)ipette  up 
to  the  mark  1  and  then  the  spinal  fluid,  after  being 
thoroughly  shaken  to  insure  uniform  suspension  of 
the  cells,  up  to  the  mark  11;  the  pipette  is  then 
shaken  for  about  five  minutes  thus  mixing  the  stain 
thoroughly  with  the  fluid  and  allowing  the  acetic 
acid  which  is  in  the  staininti;  solution  sufficient  time 


THE  PRACTICE  OF  PSYCHIATRY. 


113 


to  act  upon  and  render  invisible  any  red  blood  cor- 
puscles with  which  the  fluid  may  be  more  or  less  con- 
taminated and  which  might  otherwise  interfere  with 
the  count  and  become  a  source  of  error.  As  the 
fluid  which  is  in  the  stem  of  the  pipette  does  not  be- 
come mixed  with  that  in  the  bulb  and  is  drained  off 
before  a  drop  is  taken  out  for  the  counting  chamber, 
the  dilution  in  the  bulb,  in  calculating  the  results,  is 
to  be  considered  as  in  the  proportion  of  9  parts  of 
spinal  fluid  to  1  part  of  staining  solution. 


^^^^^^:  :^=^^^=:^i  :^=^^^^:  :^^^^=:  " 



I 

' n I ^ 

r 
!  11  11  I     U    1  J 


FIG.  I.  RULING  OF  FUCHS-ROSENTHAL  COUNTING  CHAMBER. 

After  draining  off  the  fluid  in  the  stem  of  the 
pipette,  —  a  drop  or  two,  —  a  drop  of  suitable  size 
is  placed  in  the  counting  chamber,  the  cover  glass 
put  on,  and  the  count  made  after  about  a  minute  or 


-If  _ 


114  MANUAL  OF   PSYCHIATRY. 

SO,  i.e.,  after  the  cells  have  subsided  to  the  bottom 
of  the  counting  chamber  so  as  to  be  as  nearly  as  pos- 
sible in  the  same  focus  as  the  ruling  of  the  chamber. 
The  count  is  made  most  conveniently  under  rather 
low  magnifying  power  (16  mm.  objective,  lOx  eye- 
piece, Bausch  and  Lomb;  or  No.  3  objective,  No.  4 
eyepiece,  Leitz). 

The  dimensions  of  the  counting  chamber  are  4  mm. 
on  each  side  and  0.2  mm.  in  depth,  i.e.,  3.2  cu.  mm. 
As  but  0.9  of  the  mixture  in  the  counting  chamber  is 
spinal  fluid,  the  remaining  0.1  being  staining  solu- 
tion, all  the  cells  counted  in  one  chamberful  represent 
the  cell  content  of  2.88  cu.  mm.  of  spinal  fluid.  It  is 
customary  to  express  the  findings  in  number  of  cells 
per  cu.  mm.  of  spinal  fluid ;  and  this  is,  of  course,  de- 
rived simply  by  dividing  the  total  number  of  cells 
counted  over  the  entire  ruled  area  of  a  Fuchs- 
Rosenthal  chamber  by  2.88. 

It  is  always  advisable  to  make  two  or  three  counts 
and  report  the  calculated  average  rather  than  the 
result  of  a  single  count. 

The  number  of  cells  per  cubic  millimeter  of  spinal 
fluid  varies  considerably  both  in  health  and  disease, 
and  there  is  no  definite  point  of  demarkation  be- 
tween the  two.  ]\Iost  pathologists  consider  any 
number  under  5  as  a  negative  finding,  between  5  and 
10  as  doubtful,  and  ovc^r  10  as  positive. 

Where  the  clinical  data  would  lead  the  physician 
to  expect  a  positive  finding  while  the  actual  finding 
is  doubtful  or  even  negative,  the  lum})ar  puncture 
may  bo  rei)oat(Ml  at  the  end  of  ten  days.  Either 
on  first  or  second  examination  almost  all  cases  of 


THE  PRACTICE   OF  PSYCHIATRY.  115 

general  paresis  and  cerebral  syphilis  furnish  a  posi- 
tive finding;  other  psychoses  furnish,  on  the  con- 
trary, almost  invariably  a  negative  one. 

§  2.   Wassermann  Reaction. 

The  Wassermann  reaction  has  become  an  impor- 
tant aid,  in  some  cases  an  indispensable  one,  in  psy- 
chiatric diagnosis.  It  may  be  applied  either  to  the 
blood  or  to  the  cerebro-spinal  fluid,  or  to  both,  and 
may  be  of  assistance  (a)  in  differentiating  psychoses 
of  syphilitic  nature  from  others,  (6)  to  some  extent  in 
differentiating  general  paresis  from  cerebral  syphilis 
and  from  cerebral  arteriosclerosis  of  syphilitic  origin, 
and  (c)  in  judging  the  effect  of  anti-syphilitic  treat- 
ment. ^ 

Principle  of  the  Wassermann  reaction.  —  When 
blood  corpuscles  of  an  animal  of  a  given  species  are 
injected  into  an  animal  of  a  foreign  species  the  blood 
serum  of  the  second  animal  develops  the  power  of  de- 
stroying the  corpuscles  of  animals  of  the  first  species, 
that  is  to  say,  a  specific  hcemolytic  power. 

When  the  serum  of  an  animal  thus  immunized  is 
heated  for  an  hour  at  56°  C,  or  when  it  has  been  al- 
lowed to  stand  at  room  temperature  for  twenty-four 
hours,  it  loses  its  hsemolytic  power,  technically  it  is 
said  to  have  become  inactivated.  It  may,  however, 
be  reactivated,  that  is  to  say,  its  ha^molytic  power 

1  H.  Noguchi.  Serum  Diagnosis  of  Syphilis.  Philadelphia, 
1911.  —  Rosanoff  and  Wiseman.  Syphilis  and  hisanity.  A  Study 
of  the  Blood  and  Cerebrospinal  Fluid.  Am.  Journ.  of  Ins.,  Jan., 
1910.  —  Kaplan.  Serology  of  Nervous  and  Mental  Diseases.  Phila- 
delphia, 1914. 


116  MANUAL  OF  PSYCHIATRY. 

may  be  restored,  by  the  addition  of  serum  from 
another  animal,  —  one  which  has  not  been  im- 
munized and  the  serum  from  which,  therefore,  does 
not  by  itself  possess  hsemolytic  power. 

It  is  concluded  from  these  facts  that  the  hsemolytic 
power  of  the  serum  of  an  immunized  animal  is  de- 
pendent upon  two  substances:  one  which  is  chemi- 
cally unstable  (being  easily  destroyed  by  moderate 
heat  or  by  standing  at  room  temperature)  and  non- 
specific (being  present  in  fresh  serum  of  non-im- 
munized animals  as  showTi  by  reactivation),  and 
another  which  is  chemically  stable  (resisting  the 
effect  of  moderate  heating,  etc.)  and  strictly  specific 
(being  present  only  in  the  serum  of  animals  which 
have  been  immunized  by  injections  of  corpuscles). 
The  first  substance  is  called  complement,  the  second 
amboceptor. 

For  specific  haemolysis  to  occur,  then,  the  following 
ingredients  are  required,  constituting  a  hcemolytic 
system: 

blood  corpuscles  +  complement  +  ha;molytic  amboceptor. 

In  the  case  of  bacteria  the  mechanism  of  immuni- 
zation is  similar;  accordingly,  the  essential  ingredi- 
ents in  a  reaction  of  specific  bacteriolysis,  constituting 
a  bacteriolytic  system,  are: 

bacteria  +  complement  +  bacteriolytic  amboceptor. 

It  was  shown  by  Bordct  and  Gengou  that  in  any 
bacteriolytic  reaction  a  definite  proportion  of  com- 
plement is  used  up,  and  that  the  amount  of  comple- 
ment thus  ''absorbed"  or  "fixed"  may  be  used  as  a 
measure  of  the  immunity  reaction.     So  that  if  upon 


THE  PRACTICE  OF  PSYCHIATRY.  117 

mixing  in  a  test  tube  suspension  of  bacteria,  com- 
plement, and  bacteriolytic  amboceptor  we  wish  to 
determine  whether  bacteriolysis  has  taken  place,  we 
may  do  so  simply  by  testing  for  the  presence  of 
complement;  its  absence  would  prove  that  it  has 
been  used  up  and  that  the  immunity  reaction  has 
taken  place,  while  its  presence  would  prove  that 
such  reaction  has  not  taken  place. 

The  test  for  complement  is  done  simply  by  adding 
blood  corpuscles  and  hsemolytic  amboceptor;  in  the 
presence  of  complement  haemolysis  will  occur,  in  its 
absence  it  will,  of  course,  not  occur. 

The  application  of  the  phenomenon  of  fixation  of 
complement  with  resulting  inhibition  of  haemolysis, 
known  as  the  Bordet-Gengou  phenomenon,  in  a  test 
for  syphilis  is  due  to  Wassermann. 

In  the  case  of  syphilis  the  ingredients  of  the  im- 
munity reaction  are: 

syphilitic  antigen  ^  +  complement  +  syphilitic  amboceptor. 

The  actual  test  is  performed  in  two  stages.     In 


1  Antigen  is  a  general  term  applied  to  all  bodies,  such  as  bacteria, 
blood  corpuscles,  etc.,  which  are  capable  of  exciting  the  generation 
of  specific  antibodes.  The  Treponema  -pallidum,  not  having  as  yet 
been  successfully  cult  ivated  on  artificial  media,  Wassermann  employed 
as  syphilitic  antigen  watery  extract  of  livers  from  congenitally  syph- 
ilitic infants.  It  has  since  been  found  that  ccTtain  lipoid  sub- 
stances which  may  be  extracted  from  normal  body  tissues,  curiously 
enough,  possess,  like  true  sj-pliilitic  antigen,  the  property  of  binding 
complement.  Such  lipoids  are  now  frequently  employed  as  artificial 
Byphilitic  antigen."  It  is  to  be  judged  from  this  that  the  Wasser- 
mann reaction  is  not  real!}'  an  instance  of  the  Bordet-Gengou  phe- 
nomenon, but  a  purely  empirical  and  unexplained  test  for  sypliilis 
which,  moreover,  is  not  strictly  specific 


118  MANUAL  OF  PSYCHIATRY. 

the  first  stage  syphilitic  antigen,  complement,  and 
the  serum  to  be  tested  are  brought  together;  if  the 
serum  contains  syphilitic  amboceptor  the  reaction 
will  take  place  and  complement  will,  consequently,  be 
used  up;  if  the  serum  does  not  contain  syphilitic 
amboceptor  the  reaction  will  not  take  place  and 
complement  will  therefore  remain  free.  The  second 
stage  of  the  reaction  consists  simply  in  the  addition 
of  blood  corpuscles  and  hsemolytic  amboceptor  to 
test  for  complement;  in  the  case  of  a  syphilitic 
serum,  complement,  having  been  used  up  in  the 
first  stage  of  the  reaction,  will  not  be  available  for 
the  hsemolytic  system  and  there  will  be  no  haemolysis ; 
in  the  case  of  a  non-syphilitic  serum,  complement  will 
remain  free  after  the  first  stage  of  the  test;  it  will 
therefore  be  available  for  the  hajmolytic  system,  and 
haemolysis  will  take  place. 

Preparation  of  Reagents.  —  Complement  is  derived 
from  fresh  guinea  pig  serum,  the  following  being  the 
most  convenient  way.  A  full-grown  guinea  pig  is  held 
by  an  assistant  over  a  large  Petri  dish  in  a  hyperex- 
tended  position  by  grasping  the  head  with  one  hand 
and  all  the  four  legs  with  the  other.  A  long  slender 
sharp  knife  is  introduced  into  the  neck  at  the  side 
just  in  front  of  the  vertebral  column  until  it  is 
thrust  through  on  the  other  side,  when  the  edge  of 
the  blade  is  turned  ventrally  and  all  the  tissues  in 
the  front  part  of  the  neck  are  cut  through.  The 
blood  is  caught  in  the  Petri  dish,  which  is  then 
covered  and  set  aside  in  a  corner  out  of  direct  sun- 
light and  allowed  to  stand  at  room  temperature  for 
about  two  hours,  at  the  end  of  which  time  the  serum 


THE   PRACTICE  OF  PSYCHIATRY.  119 

may  be  poured  off  and  used;  or  the  Petri  dish  may 
at  the  end  of  two  hours  be  placed  in  the  refrigerator 
where  it  may  be  kept  over  night  and  used  on  the  fol- 
lowing morning;  but  standing  over  night  at  room 
temperature  renders  the  serum  inactive.  If  kept  on 
ice  the  activity  of  the  serum  is  reduced  much  more 
slowly,  so  that  it  usually  remains  good  for  about 
forty-eight  hours. 

In  performing  the  test  0.1  c.c.  of  this  serum  is  used. 
Guinea-pig  serum  is  very  rich  in  complement,  so 
that  the  amount  used  in  the  test  is  really  in  excess 
of  that  actually  required  for  complete  haemolysis. 

It  is  customary  to  use  sheep  corpuscles  in  the  hse- 
molytic  system.  The  blood  of  a  freshly  slaughtered 
sheep  is  collected  in  a  sterile  vessel,  defibrinated, 
centrifuged,  and  the  corpuscles  washed  at  least  five 
times  with  0.9%  sodium  chloride  solution  in  distilled 
water,  by  pouring  off  the  supernatant  serum  or  salt 
solution,  adding  fresh  salt  solution,  shaking  the 
centrifuge  tube,  and  centrifuging  again.  The  washed 
sheep  corpuscles  are  used  in  inununizing  rabbits  for 
the  preparation  of  anti-sheep  amboceptor;  for  this 
purpose  one  adds  to  the  corpuscles  in  the  sedimen- 
tation tube  only  about  as  much  salt  solution  as 
would  suffice  to  bring  the  corpuscle  suspension  to  the 
original  concentration  of  the  blood,  i.e.,  two  parts 
by  volume  of  the  corpuscles  in  the  sedimentation 
tube  to  one  part  of  salt  solution.  The  sheep  cor- 
puscles are  also  used  as  a  reagent  in  the  reaction; 
for  this  purpose  a  weaker  suspension  is  prepared 
containing  but  five  parts  by  volume  to  ninety-five  of 
salt  solution. 


120  MANUAL  OF  PSYCHIATRY. 

Anti-sheep  hcemolytic  amboceptor  is  derived  from 
the  blood  serum  of  a  rabbit  which  has  been  immu- 
nized by  two  injections  of  5  and  8  c.c.  of  sheep  cor- 
puscles, respectively,  in  the  above-mentioned  con- 
centration, at  an  interval  of  five  days.  A  full-grown 
male  rabbit  weighing  about  five  pounds  is  preferred, 
and  the  injections  are  made  into  the  ear  vein  with 
a  10  c.c.  syringe.  To  facilitate  the  injections  the 
assistant  holding  the  rabbit  places  his  thumb  at  the 
root  of  the  ear  thus  impeding  the  blood  return  and 
rendering  the  vein  prominent.  A  needle  about  two 
inches  long,  gage  20,  is  used.  Subcutaneous  injec- 
tion is  useless  and  may  simply  result  in  a  slough; 
therefore,  if,  as  the  injection  is  begun,  a  swelling 
forms,  the  needle  must  be  either  readjusted  or  re- 
inserted until  proper  penetration  into  the  vein  is 
assured.  On  the  ninth  day  after  the  second  injection 
a  small  amount  of  blood  is  withdrawn,  centrifuged, 
and  the  serum  tested  for  hsemolytic  power.  If  a  dilu- 
tion of  1 :  1500  is  capable  of  hsemolyzing  with  the  aid 
of  guinea  pig  complement  a  5%  suspension  of  sheep 
corpuscles  in  about  half  an  hour,  then  the  rabbit  is 
ready  for  bleeding.  If  not,  it  may  be  necessary  to 
give  a  third  injection  of  sheep  corpuscles  and  again 
wait  eight  or  nine  days.  When  this  preliminary 
test  gives  a  satisfactory  result,  the  rabbit  is  exsan- 
guinated, the  blood  being  collected  in  a  sterile 
bowl,  covered,  and  allowed  to  stand  at  room  tem- 
perature for  twelve  or  sixteen  hours.  The  serum 
is  then  distributed  in  small  sterile  test  tubes,  put- 
ting about  2  c.c.  in  each  and  adding  salt  solution 
containing  tricresol  in  small  amount  so   that  the 


THE  PRACTICE  OF  PSYCHIATRY.  121 

concentration  of  the  latter  does  not  exceed  1  :  2000. 
The  tops  of  the  tubes  are  sealed  with  a  blow-pipe 
and  they  are  placed  on  ice.  In  this  way  the  am- 
boceptor serirni  may  be  preserved  for  three  or  fom* 
months. 

Kaplan  has  pointed  out  that  the  preliminary 
standardization  of  the  amboceptor  serum  does  not 
suffice  to  gauge  its  hsemolytic  power  under  the  con- 
ditions of  the  Wassermann  reaction,  owing  to  the 
slight,  but  appreciable,  non-specific  inhibiting  power 
of  normal  blood  serum  and  of  whatever  antigen  may 
be  used.  It  will,  therefore,  tend  to  eliminate  error  if, 
on  each  day  when  the  examination  of  a  series  of 
specimens  is  undertaken,  the  amboceptor  serum  is 
standardized  anew  in  the  presence  of  a  non-syphilitic 
serum  and  the  usual  amount  of  antigen.  This  has 
the  fm-ther  advantage  of  making  possible  the  allow- 
ance for  any  change  that  may  have  taken  place  in 
the  strength  either  of  the  amboceptor  or  of  the 
antigen. 

The  standardization  is  carried  out  as  follows. 
Six  test  tubes,  about  10  cm.  long  and  1  cm.  in  di- 
ameter, are  placed  in  a  rack,  and  into  each  are  put 
0.2  c.c.  non-syphilitic  serum,  the  usual  quantity  of 
antigen,  0.1  c.c.  complement,  and  1.0  c.c.  5%  sheep 
corpuscle  suspension;  the  rack  is  then  placed  in  the 
incubator  for  one  hour,  at  the  end  of  which  time  the 
amboceptor  serum  is  added  in  amounts  varying  from 
a  concentration  of  1  :  200  to  one  of  1  :  6400,  as  shown 
in  the  following  sample  titration;  the  rack  is  re- 
turned to  the  incubator  and  the  reading  taken  at 
the  end  of  two  hours. 


122  MANUAL  OF  PSYCHIATRY. 

Amboceptor  serum  1  :   200 Complete  haemolysis, 

"  "  1  :    400 " 

"  "  1  :    800 "  " 

"  "  1  :  1600 " 

"  1  :  3200 Slight  inhibition. 

"  1  :  6400 Marked      " 

The  rule  for  actual  work  is  to  use  double  the 
amount  of  amboceptor  which  is  sufficient  to  give 
complete  haemolysis  under  conditions  such  as  those 
of  the  above  titration.  Accordingly  one  would  select 
in  this  case  an  amount  of  amboceptor  serum  to  give 
a  concentration  of  1  :  800  or  1  :  1000. 

Antigen  may  be  prepared  in  many  different  ways, 
and  it  is  immaterial  which  of  these  is  chosen,  the 
serviceableness  of  the  product  depending  not  so 
much  on  the  method  of  preparation  as  on  the  care 
and  results  of  its  standardization.  The  method  that 
seems  capable  of  yielding  a  most  uniform  product  is 
that  of  Noguchi:  thoroughly  mashed  beef  liver  or 
kidney  is  steeped  in  ten  times  its  volume  of  absolute 
alcohol  in  the  incubator  for  seven  days,  at  the  end 
of  which  time  it  is  filtered  and  the  filtrate  evaporated 
with  the  aid  of  an  electric  fan  to  the  consistency  of  a 
thick,  sticky  mass;  this  mass  is  dissolved  in  a  small 
quantity  of  ether,  the  solution  is  filtered,  and  to  the 
filtrate  is  added  five  times  its  volume  of  acetone ;  the 
precipitate  which  is  thrown  down  immediately  is 
allowed  to  settle  and  is  taken  up  after  the  super- 
natant fluid  has  been  decanted.  0.2  gram  of  this 
precipitate  is  dissolved  in  5  c.c.  of  ether  and  to  this 
100  c.c.  of  0.9%  salt  solution  is  gradually  added;  the 
resulting  emulsion  is  filtered  through  paper  to  re- 
move flocculi  or  solid  particles.     This  emulsion  can 


THE  PRACTICE  OF  PSYCHIATRY.  123 

be  kept  on  ice  for  weeks  without  deteriorating,  and 
the  stock  mass  of  antigen  can  be  kept  even  for 
months  under  acetone  also  on  ice. 

Antigen  thus  prepared  possesses,  on  the  one  hand, 
true  antigenic  power,  that  is  to  say,  the  power  of 
binding  complement  in  the  presence  of  a  syphilitic 
serum  and  thus  inhibiting  haemolysis,  and,  on  the 
other  hand,  generally  in  a  lesser  degree,  an  anti- 
complementary  power,  that  is  to  say,  a  power  of  de- 
stroying complement  and  thus  inhibiting  haemol- 
ysis without  the  intervention  of  a  syphilitic  serum. 
It  must  therefore  be  standardized  with  a  view  to  de- 
termining the  proper  dosage  to  be  used  in  the  work 
to  insure  ample  antigenic  action  and  to  exclude 
simple  anti-complementary  action.  For  this  pur- 
pose a  titration  is  carried  out  in  the  following  manner: 
twenty  small  test  tubes  are  arranged  in  two  rows  in  a 
suitable  rack;  one  puts  into  each  test  tube  1  c.c. 
of  sheep  corpuscle  suspension  and  0.1  c.c.  of  com- 
plement, prepared  as  described  above;  to  each  of 
the  tubes  in  the  front  row  one  adds  also  0.2  c.c.  of 
serum  from  a  sj^hilitic  subject,  known  to  give  a 
positive  reaction;  one  adds  finally  to  the  test  tubes 
in  both  rows  the  antigen  emulsion  in  amounts  vary- 
ing from  0.03  c.c.  in  the  first  test  tube  to  1.0  c.c.  in 
the  tenth,  as  shown  in  the  following  sample  titration. 
The  rack  is  then  placed  in  the  incubator  for  one  hour, 
at  the  end  of  which  time  two  units  of  amboceptor 
serum  are  added  to  each  tube  in  both  rows  and  the 
rack  is  again  placed  in  the  incubator;  at  the  end  of 
two  hours  of  the  second  incubation  the  reading  is 
taken. 


124 


MANUAL  OF  PSYCHIATRY. 


Amount  of 

An  igen 
Emulsion. 

Front  row  of  tubes: 

Back  row  of  tubes:  in- 

inhibition of  ha3molysis 

hibition  of  haemolysis 

due  to  true  antigenic 
action. 

due  to  simple  anti- 
complementary action. 

0.03  c.c. 

Complete  haemolysis 

Complete  haimolysis. 

0.05  c.c. 

11                                 u 

It                  (I 

0.07  c.c. 

Partial  inhibition. 

<(                  <t 

0.10  c.c. 

Complete     " 

"                  '< 

0.12  c.c. 

H                          l( 

((                  (( 

0.20  c.c. 

(1                 <( 

((                  (( 

0.25  c.c. 

"              " 

"                  " 

0.50  c.c. 

"             " 

Partial  inhibition. 

0.75  c.c. 

I<                 it 

Complete     " 

1.00  c.c. 

The  proper  dosage  of  a  specimen  of  antigen  giving 
on  titration  results  like  those  represented  above 
would  be  0.12  c.c. 

It  happens  sometimes  that  a  specimen  of  antigen 
is  found  on  titration  to  possess  either  too  feeble  an 
antigenic  power  or  too  strong  an  anti-complemen- 
tary power;  in  either  case  it  cannot  be  used  and 
another  lot  must  be  prepared. 

Collection  of  specimens  for  examination.  —  The 
only  equipment  required  for  obtaining  a  blood  speci- 
men is  a  test  tube,  hollow  needle  about  an  inch  and  a 
half  long,  gauge  19,  with  a  short  piece  of  rubber  tub- 
ing attached  to  it,  and  a  tourniquet  consisting  simply 
of  a  piece  of  rubber  tubing  about  sixteen  inches 
long.  The  tourni(iuet  is  applied  well  up  on  the 
arm  tightly  enough  to  impede  the  venous  but 
not  the  arterial  flow;  it  is  more  convenient  to 
take  the  blood  from  the  left  arm.  Having 
selected  the  largest  sized  superficial  vein  just 
above  the  bend  of  the  elbow,  the  thumb  of  the  left 


THE  PRACTICE  OF  PSYCHIATRY.  125 

hand  is  placed  on  the  vein  partly  to  fix  it  and  prevent 
its  slipping  and  partly  to  guide  the  point  of  the 
needle;  the  needle  then,  held  in  the  right  hand  with 
the  rubber  tube  projecting  into  the  test  tube  which 
is  also  held  in  the  right  hand  being  grasped  with  the 
little  and  ring  fingers,  is  thrust  into  the  vein  at  a 
point  as  close  as  possible  to  where  it  is  held  by  the 
thumb  of  the  left  hand;  in  doing  so  the  needle  is 
held  with  the  bevel  of  its  point  upwards;  the  direc- 
tion of  the  thrust  is  inwards  and  upwards  in  the 
direction  of  the  vein.  If  the  vein  has  been  properly 
penetrated  blood  will  begin  to  trickle  into  the  test 
tube  either  immediately  or  in  a  second  or  two.  If 
it  seems  that  the  needle  has  pierced  through  the  vein 
instead  of  into  it,  blood  may  be  started  through  it 
by  withdrawing  it  slightly.  About  6  or  7  c.c.  of 
blood  is  allowed  to  flow  into  the  test  tube,  the  needle 
withdrawn,  and  the  puncture  protected  with  a  piece 
of  sterile  gauze  fastened  on  with  a  strip  of  adhesive 
plaster.  It  goes  without  saying  that  the  needle, 
test  tube,  etc.,  are  sterilized  before  being  used  and 
that  the  physician's  hands  and  the  patient's  arm 
around  the  site  of  the  puncture  are  scrubbed  properly. 

The  test  tube  containing  the  blood  is  stopped 
with  a  cotton  plug  and  allowed  to  stand  at  room 
temperature  for  several  hours,  at  the  end  of  which 
time  the  serum  may  be  examined  for  the  reaction  or 
it  may  be  placed  in  the  refrigerator  to  be  examined 
on  the  following  day. 

Specimens  of  cerebro-spinal  fluid  are  obtained  by 
lumbar  puncture,  the  technique  of  which  has  already 
been  described. 


126  MANUAL  OF  PSYCHIATRY. 

Both  the  blood  serum  and  the  cerebro-spinal  fluid 
should  be  examined  if  possible  either  on  the  same  or 
on  the  following  day  after  they  have  been  obtained, 
as  even  if  kept  on  ice  they  soon  begin  to  undergo 
changes  consisting  most  commonly  of  a  develop- 
ment of  non-specific  anti-complementary  power. 

Technique  of  the  reaction.  —  A  whole  rackful  of 
specimens  may  be  examined  together.  It  is  most 
convenient  to  use  a  test-tube  rack  with  spaces  for 
two  rows  of  test  tubes.  Tubes  10  cm.  long  and 
1  cm.  in  diameter  are  best  for  the  purpose.  For 
testing  each  specimen  two  tubes  are  used,  a  front 
tube  for  the  reaction  and  a  rear  tube  for  control. 

All  the  blood  specimens  to  be  examined  are  first 
inactivated  by  being  placed  for  three  quarters  of  an 
hour  in  a  thermostat  at  a  temperature  not  exceeding 
56°  C.  Spinal  fluids  do  not  require  to  be  inacti- 
vated. 

0.2  c.c.  of  the  serum  or  spinal  fluid  to  be  examined 
is  put  in  a  front  tube  and  the  same  amount  in  a  cor- 
responding rear  tube.  At  the  end  of  the  rack  two 
pairs  of  tubes  are  reserved  respectively  for  the  posi- 
tive and  negative  controls:  in  the  positive  control 
tubes  serum  or  cerebro-spinal  fluid  known  to  give  a 
positive  reaction  is  used;  in  the  negative  control 
tubes  neither  serum  nor  spinal  fluid  is  used.  To 
each  tube  is  now  added  0.1  c.c.  guinea  pig  comple- 
ment. Finally  to  cnch.  front  tube  is  added  the  proper 
dose  of  antigen  emulsion  as  detennined  by  the  titra- 
tion. It  is  well  to  dilute  the  antigen  emulsion  with 
0.9%  salt  solution  so  that  1  c.c.  of  the  dilution  will 
contain  the  proi)er  dose  of  antigen.     Salt  solution  is 


THE  PRACTICE  OF  PSYCHIATRY.      127 

now  added  to  all  the  tubes,  front  and  rear,  so  as  to 
bring  up  the  amount  in  each  to  2  c.c,  and  the  rack 
is  placed  in  the  incubator.  At  the  end  of  one  hour 
the  rack  is  taken  out  and  to  each  tube  are  added 
1  c.c.  of  5%  sheep  corpuscle  suspension  and  the 
proper  amount  of  anti-sheep  hsemolytic  amboceptor 
as  determined  by  the  titration.  As  in  the  case  of 
the  antigen,  it  is  well  to  dilute  the  amboceptor  with 
0.9%  salt  solution  so  that  1  c.c.  will  contain  the 
proper  amount  of  amboceptor.  Each  test  tube  is 
thoroughly  shaken  and  the  rack  is  returned  to  the 
incubator  for  two  hours  longer,  during  which  time 
the  tubes  are  frequently  taken  out,  inspected  and 
shaken,  and  at  the  end  of  which  time  the  readings 
are  to  be  taken.  The  positive  and  negative  control 
sets  are  inspected  first,  and  if  these  are  found  to  be 
all  right  the  readings  in  the  other  tubes  are  taken 
and  recorded.  The  rear  tubes,  containing  no  anti- 
gen, should  in  every  case  show  complete  haemolysis; 
if  any  rear  tube  shows  inhibition  of  haemolysis  it  is 
probably  due  to  non-specific  anti-complementary 
power  in  the  specimen  of  serum  or  cerebro-spinal 
fluid,  as  the  case  may  be,  and  any  inhibition  of  hae- 
molysis in  the  front  tube  in  such  a  case,  being  at- 
tributable to  the  same  cause,  is,  therefore,  inconclu- 
sive. If  the  rear  tubes  show  complete  haemolysis, 
inhibition  of  haemolysis  in  any  front  tube  indicates  a 
positive  reaction,  partial  haemolysis  indicates  a  slight 
or  doubtful  reaction,  and  complete  haemolysis  indi- 
cates a  negative  reaction. 


128  MANUAL  OF  PSYCHIATRY. 

§  3.   Chemical  Tests. 

Lange's  colloideil  gold  test.^  —  This  and  the  other 
chemical  tests  to  be  described  in  this  section  are  used 
in  the  examination  of  cerebro-spinal  fluid,  principally 
for  diagnosis  of  syphilitic  disorders. 

The  reagent  for  the  test  is  prepared  as  follows. 
One  uses  water  that  has  been  twice  distilled  and 
which  in  being  distilled  has  not  been  allowed  to 
come  in  contact  with  rubber  connections,  all  neces- 
sary connections  of  the  distilling  apparatus  being 
made  of  cork  which  has  been  well  boiled  beforehand. 
500  c.c.  of  such  double  distilled  water  is  put  into  a 
flat  bottom  flask  of  Jena  glass,  5  c.c.  of  a  2%  solution 
of  potassium  carbonate  is  added,  and  the  flask  placed 
on  wire  gauze  over  a  hot  flame;  when  the  solution 
has  reached  a  temperature  of  about  60°  C.  5  c.c.  of 
a  1%  solution  of  gold  chloride  in  distilled  water  is 
added  and  the  contents  of  the  flask  brought  quickly 
to  a  boil;  as  soon  as  the  first  steam  bubbles  arise 
remove  the  flask  from  the  flame  and  add  gradually 
4  c.c.  of  a  1%  dilution  of  commercial  formaldehyde 
(40%  solution  of  the  gas)  in  distilled  water,  shaking 
the  flask  all  the  time  until  the  fluid  becomes  of  a 
deep  red  color.  The  solution  thus  prepared  should 
be  perfectly  clear  and  without  a  bluish  tinge.  It  will 
keep  for  weeks  or  even  months. 

^  Carl  Lanpe.  Die  Aitsflokkurjg  koUoidalcn  Goldcs  durch  Ccrchro- 
spinal/lilssigkcit  bei  syphililischcn  Affcclionen  dcs  Centralncrvensys- 
tems.  Zeitschr.  f.  Chemothcrapio,  1912,  No.  1.  —  Kaplan  and 
McClelland.  The  PncipiUition  of  Colloidal  Gold.  Jouni.  Amer. 
Med.  Assoc,  Feb.  14,  1914.  —  Swalm  and  Mann.  The  Colloidal 
Gold  Test  on  Spinal  Fluid  in  Paresis  and  Other  Mental  Diseases. 
N.  Y.  Med.  Journ.,  Apr.  10,  1915. 


THE  PRACTICE  OF  PSYCHIATRY.  129 

The  only  other  solution  required  is  one  of  10% 
sodium  chloride  in  distilled  water. 

The  test  is  performed  in  the  following  way:  10 
small  test  tubes  are  placed  in  a  rack;  a  0.4%  sodium 
chloride  solution  in  distilled  water  is  prepared  from 
the  10%  stock  solution;  of  this  diluted  solution  one 
puts  in  the  first  test  tube  in  the  rack  1.8  c.c.  and 
in  the  other  nine  1  c.c.  each;  0.2  c.c.  of  the  spinal 
fluid  to  be  examined  is  then  put  into  the  first  test 
tube,  making  therein  a  dilution  of  1  :  10;  from  this 
1  c.c.  is  taken  out  and  put  into  the  second  test 
tube,  making  therein  a  dilution  of  1  :  20 ;  this  is  re- 
peated until  the  entire  series  of  tubes  contain  dilu- 
tions of  the  spinal  fluid  of  descending  strength,  that 
in  the  tenth  tube  being  a  dilution  of  1  :5120;  in 
order  to  make  the  volume  of  the  mixture  in  the 
tenth  tube  the  same  as  in  the  other  tubes  1  c.c.  is 
taken  out  and  thrown  away;  to  each  tube  is  now 
added  5  c.c.  of  the  colloidal  gold  solution,  the  mix- 
ture shaken  up,  and  the  rack  left  to  stand  at  room 
temperature  for  twenty-four  hours,  when  the  read- 
ing is  taken. 

In  recording  the  reading  it  is  customary  to  dis- 
tinguish five  degrees  of  intensity  of  the  reaction;  a 
negative  reaction  leaves  the  fluid  in  the  test  tube  red 
as  in  the  beginning,  and  is  designated  0;  a  veiy 
slight  reaction  will  leave  the  fluid  still  quite  red 
but  with  a  distinct  blue  tinge,  and  is  designated  1; 
a  somewhat  stronger  reaction  renders  the  fluid  blue 
but  with  a  distinct  red  tinge  still  remaining,  and  is 
designated  2;  the  next  intensity  of  reaction  is  indi- 
cated by  a  dark  blue  color,  and  is  designated  3;   the 


130 


MANUAL  OF   PSYCHIATRY. 


next  again  by  a  pale  blue  color,  and  is  designated  4; 
and  finally  the  strongest  intensity  of  reaction,  being 
marked  by  complete  precipitation  of  the  colloidal 
gold,  is  indicated  by  a  colorless  condition  of  the 
supernatant  fluid,  and  is  designated  5. 

For  a  proper  interpretation  of  the  findings  it  is 
necessary  to  record  not  only  the  fact  of  a  positive 
reaction  or  its  intensity,  but  also  the  intensity  of 
the  reaction  in  each  of  the  tubes;  accordingly  the 
reading  is  best    recorded   either  in  the   form  of  a 


Intensity  of 

Spinal  Fluid  Dilution,  1  part  in 

Keaction. 

10 

20 

40 

SO 

100 

320 

040 

1280 

2560 

5120 

5 

Colorless 

N 

4 

Pale  blue 

X 

3 

Dark  blue 

X 

2 

Blue  red 

--\ 

V 

1 

Red  blue 

0 

Red 

FIG.    2.     GOLD    CHLORIDE    CURVE. 


chart,  like  that  given  in  the  accompanying  illustra- 
tion, or  in  that  of  a  row  of  figures  representing  the 
reactions  in  the  ten  test  tubes  in  the  same  order  in 
which  they  are  ranged  in  the  rack;  thus  the  curve 
on  the  chart  may  also  be  expressed  in  this  way: 
5555432000. 


THE  PRACTICE  OF  PSYCHIATRY.  131 

Noguchi's  butyric  acid  test.^  —  To  0.2  c.c.  of  cerebro- 
spinal fluid  in  a  small  test  tube  is  added  0.5  c.c.  of 
an  aqueous  solution  containing  10%  of  butyric  acid 
and  0.9%  of  sodium  chloride,  and  the  mixture  is 
heated  over  a  flame  until  it  boils;  while  it  is  still 
hot  0.1  c.c.  of  a  4%  solution  of  sodium  hydroxide  is 
added  and  the  mixture  is  boiled  again.  A  positive 
result  is  indicated  by  the  appearance  at  once  or 
after  a  few  minutes  of  a  finely  granular  or  flocculent 
precipitate  which  settles  in  a  little  while,  the  super- 
natant fluid  remaining  clear.  If  no  precipitate  forms 
or  if  only  a  diffuse  opalescence  develops  which  does 
not  subside  on  standing,  the  reaction  is  recorded  as 
negative. 

Ross- Jones  ammoRium  sulphate  test.^ — Upon  2  c.c. 
of  a  saturated  solution  of  ammonium  sulphate  in  a 
test  tube  1  c.c.  of  cerebro-spinal  fluid  is  allowed  to 
flow  gently  from  a  pipette  in  such  a  manner  that  it 
will  form  a  layer  floating  on  top.  The  reaction  is 
positive  if  within  a  few  minutes  a  thin  grayish  ring 
is  formed  at  the  junction  of  the  two  liquids.  After 
standing  the  ring  becomes  thicker  and  on  close  ex- 
amination in  a  suitable  light  against  a  dark  back- 
ground may  be  seen  to  be  made  up  of  a  fine  network 
of  cobweb-like  appearance. 

§  4.   BixET-SiMON  Tests. 
The  importance  of  ascertaining  a  patient's  con- 
stitutional make-up  has  already  been  pointed  out. 

^  Noguchi  and  Moore.  Journ.  Exper.  Med.,  Vol.  XI,  1909,  p. 
604.  —  Rosanoff  and  Wiseman.  Syphilis  and  Insanity.  Amer. 
Journ.  of  Insanity,  Vol.  LXVI,  1910,  p.  419. 

2  British  Med.  Journ.,  1909,  Vol.  I,  p.  1111. 


132  MANUAL  OF  PSYCHIATRY. 

Anomalies  of  make-up  may  be  either  temperamental 
or  intellectual.  For  a  more  accurate  study  of  the 
latter  a  system  of  tests  has  been  devised  by  Binet 
and  Simon,  constituting  a  measuring  scale  oj  intelli- 
gence. These  tests  have  been  applied  to  normal 
children  of  various  ages  and  have  thus  been  stand- 
ardized, so  that  it  is  now  possible  by  means  of  them 
to  estimate  the  degree  of  mental  development  of  any 
subject  in  terms  of  the  age  at  which  such  develop- 
ment corresponds  to  the  nonnal  average.  The 
authors  of  these  tests  have  taken  special  pains  to 
eliminate  the  disturbing  influence  of  education,  hav- 
ing made  it  their  aim  to  devise  a  measure  of  natural 
mental  capacity  and  not  of  degree  of  training. 

The  tests  are  here  described  partly  as  published  in 
the  memoir  of  Binet  and  Simon  and  partly  as  adapted 
for  English  speaking  subjects  by  Goddard  and  by 
Whipple.^ 

In  applying  these  tests  to  cases  of  insanity  one 
must  guard  against  mistaking  temporary  disability 
of  acute  psychotic  conditions  or  acquired  disability 
of  states  of  dementia  for  inferiority  of  original  mental 
endowment.  In  the  presence  of  acute  psychotic 
manifestations  these  tests  are  not  to  be  applied,  but 
one  should  rathc^r  wait  until  such  manifestations 
have  subsided  and  the  j^atient  is  sufficiently  com- 
posed to  give  full  cociporatiou. 

'  liiiiot  and  Simon.  Jj;  (levdoppcmenl  de  I' in kUu/cnce  chez  les 
enjanls.  L'Annco  jisychol.,  Vol.  XIV,  1908.  (I'^n^lish  tranwlation 
by  Clara  H.  Town.  Lincoln,  111.,  1913.)— H.  H.  Goddard.  A 
Measuring  Scale  of  Intellujence.  The  Training  School,  Jan.,  1910. 
—  G.  M.  Whipple.  Manual  of  Mental  and  Physical  Tests.  First 
edition.     Baltimore,  1910. 


THE   PRACTICE  OF  PSYCHIATRY.  133 


Children  of  Three  Years. 

1.  Where  is  your  nose?     Your  eyes?     Your  mouth? 

These  questions  test  comprehension  of  language  and  can 
be  answered  by  gestures. 

2.  Rejielition  of  sentences. 

Papa.     (2  syllables.) 

Slipper.     Letter.     (4  syllables.) 

It  is  cold  arid  snowing.     (6  syllables.) 

/  have  a  dog;   he's  a  fine  one.     (8  syllables.) 

His  name  is  Jack.     Oh,  what  a  naughty  boy.     (10  syllables.) 

It  is  raining  outdoors,  but  we  can  stay  inside.     (12  syllables.) 

We  are  having  a  fine  time,  we  found  a  mouse  in  the  trap. 
(14  syllables.) 

Let's  all  go  for  a  walk  to-day.  Please  give  me  that  big  hat  to 
ivear.     (16  syllables.) 

Poor  Helen  has  just  torn  her  neiv  dress.  She  will  surely  feel 
sorry  for  that.     (18  syllables.) 

Why  should  any  one  loant  to  do  injury  to  such  beautiful 
creatures  as  birds  ?     (20  syllables.) 

We  expect  to  have  a  great  time  at  the  seashore,  digging  in  the 
white  beach  sand  all  day  long.     (22  syllables.) 

When  the  train  crosses  the  road  Hie  engineer  will  blow  the 
ichistle  and  the  fireman  will  ring  the  bell.     (24  syllables.) 

My  young  brother  Frank  had  a  fine  time  on  his  vacation  this 
summer;  he  went  fishing  almost  every  day.  (26  syl- 
lables.) 

To  start  a  fire  in  the  open  is  one  of  those  tricks  that  everyone 
thinks  he  can  perform  until  he  tries  it.     (28  syllables.) 

He  sinks  the  net  in  the  water  and  waits  until  he  can  see  the  fish 
distinctly,  lying  perfectly  still  and  within  reach.  (30 
syllables.) 


134 


MANUAL  OF  PSYCHIATRY. 


THE  PRACTICE  OF  PSYCHIATRY. 


135 


FIG.   5. 

The  average  child  of  three  years  will  repeat  a  sentence  of 
six  syllables  but  not  of  ten.  At  six  years  all  children 
can  repeat  a  sentence  of  sixteen  syllables.  At  twelve 
a  child  should  be  able  to  repeat  a  sentence  of  twenty- 
six  syllables.  The  test  is  passed  only  when  the  sen- 
tences are  repeated  without  a  single  error. 

3.  Repetition  of  figures:  3,  7;  6,  4. 

As  a  rule,  a  child  of  three  years  cannot  repeat  more  than 
two  figures. 

4.  Description  of  pictures.^     (Figs.  3,  4,  and  5.) 

1  Goddard  recommends  a  special  set  of  eight  pictures  because 
it  is  a  larger  series,  because  the  subjects  represented  are  better 
adapted  to  a  child's  intelligence,  and  because  they  are  colored.  Sets 
of  these  pictures  may  be  obtained  through  the  Training  School  at 
Vineland,  N.  J. 


136  MANUAL  OF   PSYCHIATRY. 

What  do  yon  see  there? 

At  least  three  different  types  of  responses  are  obtained, 
characteristic  of  different  degrees  of  mental  develop- 
ment. A  child  of  three  merely  enumerates  objects 
represented  in  the  picture.  A  child  of  seven  describes 
objects  and  action:  "  A  man  and  a  little  boy  drawing 
a  cart."  A  child  of  twelve  interprets:  "  A  poor  man 
moving  his  furniture."  "  These  are  some  unfortunates 
who  have  no  place  to  sleep."     "  This  is  a  prisoner." 

5.  What  is  your  name? 

Children  of  three  years  know  their  given  name;  they  do  not 
always  know  their  family  name. 

Children  of  Four  Years. 

6.  Are  you  a  little  hoy  or  a  little  girl? 

Children  of  three  years  often  answer  incorrectly,  those  of 
four  years  always  answer  correctly. 

7.  Naming  familiar  objects. 

What  is  this?  (Key.)  And  this?  (Knife.)  And  this? 
(Penny.) 

8.  Repetition  of  three  figures:  7,  2,  9. 

9.  Comparison  of  two  lines:  Which  line  is  longer? 

Draw  two  lines,  parallel  to  each  other,  5  and  G  cm.  long 
respectively,  3  cm.  apart.  Hesitation  is  failure  in 
the  test. 

Children  of  Five  Years. 

10.  Comparison  of  weights:   Which  is  heavier? 

U.se  weighted  blocks  of  wood  of  equal  size  and  appearance. 
Comparison  is  between  3  gms.  and  12  gms.  and  l)e- 
tween  6  gms.  and  15  gms.  If  necessary  the  child  may 
be  assisted  by  the  suggestion  to  take  up  the  weights 
in  the  hands,  l)ut  must  not  be  .shown  iiow  to  handle 
and  compare  the  weights. 

11.  Copying  a  square. 

One  draws  a  stjuare  of  'A  or  4  cm.  and  the  child  is  asked  to 
copy  it  with  pen  and  ink,  not  with  i)encil.  Fig.  S 
shows  results  that  may  be  rec()rd(>d  as  satisfactory 
(upper  row  of  scjuares)  and  .sonic  that  should  not  be 
rec<)rd(Ml  as  satisfactory  (lower  row),  the  drawings  not 
being  recognizable  as  sfjuares. 


THE  PRACTICE  OF  PSYCHIATRY.  137 


] 


FIG.  6. 

12.  Restoring  divided  rectangle. 

Two  visiting  cards  of  equal  size  and  shape  may  be  used. 
One  is  cut  diagonally  in  two  and  the  pieces  are  placed 
on  the  table  before  the  child  -with  the  hypothenuses 
away  from  each  other;  the  uncut  card  is  also  placed 
on  the  table  and  the  child  is  asked  to  put  the  two 
triangular  pieces  together  so  as  to  make  a  figure  like 
the  uncut  card.  If  in  the  attempt  the  child  turns 
one  of  the  pieces  wrong  surface  up  the  examiner 
should  turn  it  right  surface  up  again  so  that  the  proper 
apposition  would  be  possible;  no  other  assistance 
should  be  given  and  the  examiner  must  not  betray  by 
look  or  gesture  whether  the  child  is  right  or  wrong. 

13.  Counting  four  pennies. 

The  pennies  are  placed  in  a  row  and  the  child  must  point 
to  each  one  separately  in  counting. 


Children  of  Six  Years. 

14.  Show  me  your  right  hand;  your  left  ear. 

No  hint  by  look  or  word  must  be  given. 

15.  Repetition  of  sentences  of  sixteen  syllables. 

See  Test  2. 

16.  Esthetic  comparisons:  Which  is  the  prettier? 

Fig.  9. 


138 


MANUAL  OP  PSYCHIATRY. 


FIG.    7. 


THE  PRACTICE  OF  PSYCHIATRY. 


139 


,^^ 


FIG.  8. 


140  MANUAL  OF  PSYCHIATRY. 

17.  Definitions  of  familiar  objects:  What  is  a  fork?  A  table?  A 
chair?     A  horse?     A  mamma? 

Three  principal  types  of  responses  are  met  with:  a.  Silence, 
simple  repetition,  or  indication  by  gesture:  test  is  not 
passed,  h.  Definitions  in  terms  of  use:  "  A  fork  is  to 
eat  with."  (Children  of  six  years.)  c.  Definitions 
superior  to  the  above:  "  A  fork  is  a  utensil  for  eating." 
"  A  mamma  is  a  woman  who  takes  care  of  her  chil- 
dren."    (Children  of  nine  years.) 

18.  Execution  of  triple  order:  Here  is  a  key;  please  put  it  on  that 
chair;  then  shut  the  door;  then  you  will  notice  a  box  on-  the  chair 
near  the  door;  please  bring  me  that  box.  Do  you  understand? 
Remember,  first  put  the  key  on  the  chair,  then  shut  the  door,  then 
bring  me  the  box.     Now,  go  ahead. 

19.  How  old  are  you? 

20.  Is  this  morning  or  afternoon? 

Some  children  often  select  the  latter  of  two  alternatives, 
therefore  if  it  is  afternoon  the  question  might  better 
be  worded  in  reverse  order :  7s  this  afternoon  or  morning? 

Children  of  Seven  Years. 

21.  Unfinished  pictures:  What  is  lacking  in  this  picture? 

To  pass  the  test  three  out  of  four  answers  must  be  correct. 
(Fig.  10.) 

22.  How  many  fingers  have  you  on  your  right  hand?  How  many 
on  your  left  hand?     How  mayiy  07i  both? 

23.  Writing  from  copy:  See  little  Paul. 

Copy  must  be  written  for  the  child  in  a  large  legible  hand. 

24.  Copying  a  diamond. 

Children  can  generally  copy  a  square  at  the  age  of  five, 
but  a  diamond  not  until  the  age  of  seven.  Fig.  11 
shows  results  that  may  be  recorded  as  satisfa(;tory 
(upper  row  of  diamonds)  and  some  that  should  not 
be  recorded  as  satisfactory  (low(>r  row),  the  drawings 
not  being  recognizable  as  diamonds. 

25.  Repetition  of  five  figures:  I,  7,  3,  9,  5. 
2().    Description  of  a  piclure. 

See  Test  4. 

27.  Moulding  thirteen  pennies. 

The  pennies  an;  placed  in  a  row  and  the  child  must  point 
to  each  one  separatc^ly  in  counting. 

28.  Naming  four  couunon  coins:  penny,  nickel,  dime,  quarter. 


THE  PRACTICE  OF   PSYCHIATRY. 


141 


A 


Children  of  Eight  Years. 

29.    Reading  and  relating. 

The  child  is  asked  to  read  aloud  the  following  news  item; 
the  time  occupied  in  the  reading  is  recorded  in  seconds; 
a  record  is  made  also  of  the  manner  of  reading:  whether 
letter-by-letter,  by  syllables,  or  hesitating,  fluent,  or 
expressive;  at  the  same  time  note  is  taken  of  any  word 
that  is  misread. 

THREE   HOUSES   BURNED. 
Boston,  September  5th.    A  serious  fire  last  night  destroyed  three 
houses  in  the  center  of  the  city.     Seventeen  families  are  without  a 
home.    The  loss  exceeds  fifty  thousand  dollars.    In  rescuing  a  child 
one  of  the  firemen  was  badly  burned  about  the  hands  and  arms. 

Average  time  occupied  in  the  reading  is  for  children  of 
eight  years  45  seconds;  for  children  of  nine,  ten,  and 
eleven  years  40,  30,  and  25  seconds  respectively. 
A  few  seconds  after  the  child  has  finished  the  reading 
he  is  asked  to  relate  what  he  has  read.  The  entire 
news  item  may  be  divided  into  twenty  component 
elementary  ideas,  as  follows: 


142  MANUAL  OF  PSYCHIATRY. 

Three  houses  \  burned  \  Boston  \  September  5th  \  a  serious  fire  \  Icbst 
Tiight  I  destroyed  \  three  buildings  \  in  the  center  of  the  city  \  seventeen 
families  \  are  without  a  home  \  the  loss  exceeds  \  fifty  thousand  dollars 
in  rescuing  |  a  child  \  one  of  the  firemen  \  was  badly  |  burned  \  about 
the  hands  and  arms. 

At  the  age  of  eight  almost  all  normal  children  will  relate 
correctly  at  least  two  of  the  component  ideas.  No 
sut)ject  can  relate  correctly  six  or  more  of  the  com- 
ponent ideas  unless  he  is  able  to  read  the  text  within 
one  minute. 

30.  Counting  money:  four  pennies  and  two  nickels. 

(Binet  and  Simon  use  nine  sous  —  3  simples,  3  doubles; 
Goddard  recommends  the  use  of  3  one-cent  and  3 
two-cent  stamps.) 

31.  Naming  four  elementary  colors. 

Red,  blue,  green,  and  yellow  papers,  1x3  inches,  are  used. 

32.  Counting  back  from  twenty  to  one. 

To  pass  this  test  the  child  must  do  it  within  twenty  seconds 
and  with  not  more  than  one  error  of  omission  or 
transposition.  If  necessary  the  child  may  be  assisted 
by  starting  him  with:  "  20,  19,  18,  what  comes  next!  " 

33.  Writing  from  dictation:  The  pretty  little  girls. 

The  writing  must  be  intelligible. 

34.  Comparison  of  two  things  recalled  in  memory:  What  is  the 
difference  between  a  butterfly  and  a  fly?  Between  wood  and  glass? 
Between  paper  and  cloth? 

The  question  may  be  more  plainly  put  as  follows:  "  You 
know  what  butterflies  are,  you  have  seen  them,  have  you 
not?  —  Yes.  —  And  you  know  what  flies  are,  do  you 
not?  —  Yes.  —  Is  a  butterfly  just  like  a  fly?  —  No.  — 
In  what  are  they  not  alike?  "  —  At  six  one-third  of  the 
children  succeed  in  this  test;  at  seven  nearly  all;  at 
eight  all. 

Childre.v  of  Nine  Years. 

35.  Orientation  in  time:  What  day  of  the  week  is  to-day?  What 
month?     What  dale?     What  year? 

The  test  is  p;i.ssed  if  the  day  of  the  month  is  given  within 
three  days  of  tlie  actual  date,  either  way. 

36.  Reciting  the  days  of  the  week. 

Should  be  done  within  ten  seconds  without  any  omission 
or  transposition. 


THE  PRACTICE  OF   PSYCHIATRY.  143 

37.  Making  change. 

Play  store;  let  the  child  have  25  pennies,  5  nickels,  and 
2  dimes;  purchase  from  him  an  article  costing  9  cents 
and  make  payment  with  a  25-cent  piece,  asking  him 
to  give  change.  Scarcely  any  child  passes  this  test 
at  seven ;  one-third  succeed  at  eight;  all  succeed  at  nine. 

38.  Definilions  of  familiar  objects. 

See  Test  17. 

39.  Reading  and  relating. 

See  Test  29. 

40.  Arrangement  of  lodghts. 

Five  wooden  blocks  of  equal  size  and  appearance,  weigh- 
ing respectively  6,  9,  12,  15,  and  18  grams,  are  used. 
The  child  is  first  told  that  the  blocks  are  not  alike  in 
weight  and  is  then  asked  to  arrange  them  in  order 
from  the  lightest  to  the  heaviest.  Three  trials  are 
made  for  which  not  over  three  minutes  is  allowed;  the 
arrangement  should  be  without  error  in  two  out  of 
the  three  trials. 

Children  of  Ten  Years. 

41.  Reciting  the  months  of  the  year. 

Should  be  done  within  fifteen  seconds  and  with  not  more 
than  one  omission  or  transposition. 

42.  Denomination  of  money,  bills  and  coins. 

Place  before  the  child  the  following  bills  and  corns  in  the 
order  as  here  given:  penny,  half-dollar,  two  dollars, 
dime,  five  dollars,  quarter,  one  dollar,  and  nickel. 
Let  the  child  name  each  piece,  pointing  to  each  one  as 
he  does  so. 

43.  Sentence  building. 

The  words  Philadelphia,  money,  river  are  written  on  a 
blank  sheet  of  paper  and  read  over  to  the  child  several 
times;  the  child  is  then  asked  to  make  a  sentence 
which  shall  contain  these  three  words.  One  obtains 
four  principal  types  of  responses:  a.  Three  separate 
sentences:  "'  Philadelphia  is  a  city;  my  father  has 
money;  the  river  is  deep."  b.  One  sentence  with  two 
distinct  ideas:  "  In  Philadelphia  there  is  a  river  and 
there  are  people  who  have  much  money."  c.  One 
sentence  in  which  the  three  words  are  combined  in 


144  MANUAL  OF  PSYCHIATRY. 

a  single  idea:  "  On  the  river  near  Philadelphia  one 
can  hire  sailboats  for  very  little  money."  d.  Several 
sentences,  hut  well  coordinated:  "  In  my  childhood  I 
lived  in  Philadelphia;  two  blocks  from  our  street 
flowe<l  the  Delaware  River;  much  money  has  since 
been  spent  in  beautifying  that  part  of  the  city."  The 
child  must  write  the  sentence;  at  the  expiration  of  a 
minute  the  sentence  must  be  at  least  three-fourths 
completed.  Responses  of  the  first  type  are  regarded 
as  failures;  those  of  the  other  types  are  given  by  few 
children  of  eight  years,  by  one-third  of  the  children 
at  nine,  and  by  one-half  at  ten;  a  child  of  elev'en  should 
give  sentences  of  the  third  or  fourth  type. 
44.    Questions  to  test  judgment:  First  series. 

Answers  to  these  questions  may  be  classed  as  correct  or 
incorrect  in  accordance  with  obvious  common  sense. 
Examples  of  correct  and  incorrect  answers  are  here 
given  in  connection  with  each  question. 

What  ought  one  to  do  when  one  has  missed  a  train?  Correct 
answers:  Wait  for  the  next  train.  Take  another 
train.  —  Incorrect  answers:  One  should  try  not  to 
miss  it.     Run  after  it.     Buy  a  ticket. 

What  ought  one  to  do  when  one  has  been  struck  by  a  playmate 
who  did  not  do  it  purposely?  Correct  answers:  Do 
nothing  to  him.  Forgive  him.  Tell  him  to  be  careful 
next  time.  —  Incorrect  answers:  Tell  the  teacher. 
Strike  him  back. 

What  ought  one  to  do  when  one  has  broken  something  belong- 
ing to  another?  Correct  answers:  Pay  for  it.  -Replace 
it.  Confess  it.  —  Incorrect  answers:  Cry.  Must  make 
him  pay.     Go  to  the  police. 

To  these  simple  (juestions  half  the  children  of  seven  and 
eight  years,  throe-fourths  of  nine  years,  and  all  of  ten 
years  respond  correctly. 
Second  scries. 

What  ought  one  In  do  when  one  is  late  for  school?  Correct 
answers:  Hurry.  Run. — -Incorrect  answers:  One  is 
punished.  One  must  start  at  an  earlier  hour.  Bring 
an  excuse  from  the  parents. 

Whal  ought  one  to  do  before  taking  part  in  an  important 
affair?  Correct  answers:  Consider  it  carefully.  Ask 
for  advice.  —  Incorrect  answer  (given  by  some  sub- 


THE  PRACTICE  OF  PSYCHIATRY.  145 

jects  of  Binet  and  Simon,  quite  irrelevant  apparently 
owing  to  imperfect  comprehension  of  the  question): 
One  must  take  care  of  the  sick.  Consult  a  physician. 
One  should  go  away. 

Why  does  one  excuse  a  wrong  act  committed  in  anger  more 
easily  than  a  ivrong  act  committed  without  anger?  Cor- 
rect answers:  Because  when  one  is  angry  one  does  not 
know  what  he  is  doing.  In  anger  one  is  not  re- 
sponsible. — ■  Incorrect  answers:  When  one  is  angry 
one  will  not  listen.     One  should  not  be  angry. 

What  should  one  do  when  asked  his  opinion  of  some  one 
whom  he  does  not  know  well?  Correct  answers:  One 
should  say  nothing.  One  should  not  speak  without 
knowing.  One  should  keep  silence  because  he  might 
give  wrong  information.  —  Incorrect  answers:  One 
should  ask  him.  One  should  answer.  One  should 
say:  Be  prudent.  One  should  say  that  he  does  not 
know  his  name. 

Why  ought  one  to  judge  a  person  more  by  his  acts  than  by  his 
words?  Correct  answers:  Because  words  may  deceive, 
but  acts  show  the  truth.  Because  one  is  more  sure 
from  seeing  the  acts  than  from  hearing  the  words.  — 
Incorrect  answers:  One  should  not  tell  a  lie.  Because 
one  does  not  know. 

The  questions  in  the  second  series  are  more  complex 
and  the  judgment  required  more  subtle.  After  each 
question  the  subject  should  be  allowed  at  least  twenty 
seconds  for  reflection.  Three  correct  responses  out 
of  five  are  sufficient  to  pass  the  test.  At  seven  or 
eight  years  no  child  passes  this  test;  not  quite  half 
pass  at  ten;  the  test  is  therefore  for  the  age  of  transi- 
tion between  ten  and  eleven. 

Children  of  Eleven  Years. 

45.   Detecting  absurdities  or  contradictions. 

The  following  explanation  is  first  made  to  the  child:  "7 
am  going  to  give  you  some  sentences  in  which  there  is 
nonsense.  You  listen  carefully  and  see  if  you  can  tell 
me  where  the  nonsense  is."  Then  the  following  sen- 
tences are  slowly  read  off  to  him  one  by  one : 

An  unfortunate  bicycle  rider  broke  his  head  and  died  from 


146  MANUAL  OF  PSYCHIATRY. 

the  fall;  Ihcy  look  him  to  the  hospital  but  they  do  not  think 

that  he  will  recover. 
I  have  three  brothers,  Paul,  Ernest,  and  myself. 
The  police  found  yesterday  the  body  of  a  young  girl  cut  into 

eighteen  pieces.     They  believe  that  she  killed  herself. 
Yesterday  there  ivas  an  accident  on  the  railroad,  but  it  was  not 

serious;  only  forty-eight  persons  were  killed. 
The  engineer  said  that  the  more  cars  he  had  on  his  train  the 

faster  he  could  go. 
To  pass  this  test  at  least  three  out  of  the  five  answers  must 

be  correct.     Hardly  any  chikl  of  nine  passes;  at  ten 

not  quite  one-fourth;  at  eleven  one-half. 

46.  Sentence  building. 

See  Test  43. 

47.  Giving  words. 

The  child  is  asked  to  give  as  many  words  as  he  can  in  three 
minutes.  He  may  be  assisted  by  being  started :  "  beard, 
table,  skirt,  carriage.'"  It  may  encourage  him  to  be  told 
that  other  children  have  given  as  many  as  two  hun- 
dred words.  At  least  sixty  words  must  be  given  to 
pass  the  test. 

48.  Definitions    of    abstract    terms:    What    is    charity?     Justice? 
Goodness? 

To  pass  this  test  two  of  the  three  definitions  must  be 
acceptable.  At  eight  or  nine  years  very  few  children 
give  acceptal^le  definitions;  at  ten  about  one-third 
do;  at  elevwi  most  children  do. 

49.  Arranging  words  in  a  sentence:  "  Make  a  sentence  out  of  these 
words." 

Hour  —  for  — ^  we  —  good  —  at  —  park  —  a  —  started  —  the. 
To  — •  asked  —  exercise  —  my  —  teacher  —  correct  —  my  —  I. 
A  —  defends  —  dog  —  good  —  his  —  courageously  —  master. 

The  printed  card  is  placed  before  the  child.  He  gives  the 
sentences  oral!}-.  Time  limit  is  one  minute  for  each 
sentence.     .\t  legist  two  must  be  given  correctly. 

Children  ov  Twelve  Years. 

50.  Repetition  of  seven  figures:  2,  9,  4,  «,  3,  7,  5.  —  1,  6,  9,  o,  8,  4,  7. 
—  9,  2,  S,  f),  1,  (),  4. 

Tell  the  cliild  tlicrc  will  tie  .seven  figures.  Give  three  trials. 
One  .success  is  sufficient. 


THE   PRACTICE  OF  PSYCHIATRY.  147 

51.  Finding  rhymes. 

Explain  what  is  meant  by  one  word  rhyming  with  another 
and  illustrate  by  means  of  examples.  Then  ask  the 
child  to  give  as  many  words  as  he  can  think  of  that 
rhyme  with  a  given  word:  day,  or  spring,  or  mill.  One 
minute  is  allowed.  Three  rhymes  to  one  word  should 
be  found  in  the  given  time. 

52.  Repetition  of  a  sentence  of  twenty-six  syllables. 

See  Test  2. 

53.  Conclusions  from  evidence. 

A  person  who  was  walking  in  the  park  stopped  in  fright  and 
ran  to  the  nearest  policeman,  saying  that  he  had  just  seen 
hanging  from  the  branch  of  a  tree  a  (after  a  pause)  what? 

My  neighbor  has  been  having  strange  visitors:  first  a  doctor, 
then  a  lawyer,  then  a  piiest.  What  has  happened  at  the 
house  of  my  neighbor? 

To  pass  this  test  both  questions  must  be  answered  correctly. 


FIG.    10. 

Children  of  Thirteen  Years. 

54.   Imagery  of  form. 

The  child  is  directed  to  watch  carefully  as  the  examiner 
slowly  folds  a  sheet  of  paper  in  four  and  then  cuts  out 
a  small  triangular  piece,  from  one  edge  —  the  edge 
which  does  not  open  (Fig.  12).     The  child  is  asked 


148  MANUAL  OF  PSYCHIATRY. 

to  draw  a  picture  of  the  paper  as  it  will  look  when 
unfolded.  Unfolding  the  cut  sheet  or  folding  another 
sheet  is  not  allowed.  This  test  is  a  difficult  one.  If 
a  child  does  it  the  first  time  he  should  be  asked  if  he 
has  seen  it  before. 
65.   Imagery  of  form. 

A  visiting  card  is  cut  diagonally  in  two  and,  with  the  two 
halves  apposed  as  originally,  is  placed  on  the  table 
before  the  child.  The  following  task  is  then  given 
him:  "  Look  carefully  at  this  card,  especially  at  this 
(lower)  half.  Suppose  we  should  turn  this  half  upside 
down,  and  place  this  corner  (c)  touching  this  point  (b) 
so  that  this  edge  (be)  shall  touch  this  edge  (ab),  what 
icould  the  whole  figure  look  like  then?  Now,  I  ajn  going 
to  pick  up  this  lower  half.  I  want  you  to  imagine  it 
turned  over  and  laid  up  against  the  upper  half  as  I  have 
said.  Draw  the  ichole  figure  for  me  as  it  would  look 
then.  Begin  with  the  upper  half  that  you  see  before  you." 
The  test  is  difficult;  the  essential  points  for  success  are 
to  preserve  the  right  angle  bca,  and  to  make  cb  shorter 
than  ba.     (Fig.  13.) 


56.    Distinctinyis  lirtircvn  abstract  t(rms. 

Wliat  is  the  (lijjtrturi'  bchrcen  pleasure  ami  happiness? 
lietn-ccn  erobdinn  and  n volution?  Bcturcn  erent  and 
advent?  Brlireen  poverty  and  misery?  Between  pride 
and  pretension? 


THE  PRACTICE  OF  PSYCHIATRY.  149 

The  tests  should  be  conducted  in  a  quiet  room  as  free 
as  possible  from  distracting  influences.  The  subject,  if 
doing  poorly  in  the  tests,  should  not  be  given  to  under- 
stand that;  but  should  be  frequently  encouraged  and 
made  to  feel  at  ease. 

As  has  already  been  stated  the  results  of  these  tests 
lead  to  a  rating  of  the  subject's  intelligence  in  terms  of 
the  age  at  which  such  intelligence,  as  shown  by  many 
trials,  corresponds  with  the  normal  average. 

In  practice  one  finds  a  good  deal  of  irregularity  in 
the  results;  subjects  frequently  respond  correctly  to 
some  tests  of  a  higher  age  and  fail  to  do  so  to  some  tests 
of  a  lower  age.  For  summary  ratings  Binet  and  Simon 
recommend  the  following  rules:  (1)  The  mental  devel- 
opment of  a  subject  is  rated  at  the  highest  age  in  the 
tests  of  which  he  has  succeeded  with  not  more  than  one 
exception.  (2)  For  every  five  tests  passed  above  the 
age  level  as  determined  by  the  .first  rule  one  year  is 
added. 

In  interpreting  the  results  of  these  tests  one  must 
bear  in  mind  the  great  differences  which  exist  between 
normal  subjects  in  rate  and  degree  of  mental  develop- 
ment. A  variation  of  one  or  even  two  years  from  the 
age  level  of  intelligence  as  established  by  these  standards 
is  by  no  means  to  be  regarded  as  necessarily  pathological. 
But  departure  of  three  years  or  more  below  these  stand- 
ards is,  of  course,  of  nuich  greater  significance  from  the 
pathological  standpoint,  as  may  be  judged  from  the 
following  tables  representing  the  results  obtained  by 
Binet  and  Simon  ^  from  French  children,  both  normal 

1  Loc.  cit. 


150 


MANUAL  OF   PSYCHIATRY. 


and  defective,  and  b}^  Goddard  ^  from  a  much  larger 
group  of  children  selected  at  random  from  the  first  five 
grades  in  a  typical  public  school  system;  Goddard's 
subjects  were  for  the  most  part  American,  some  few 
were  Jewish  and  some  Italian. 

203  Normal  French  School  Children. 


Retarded. 

At  Age. 

Advanced. 

2  Yeare. 

1  Year. 

1  Year. 

2  Years. 

12 

44 

103 

42 

2 

14  French  School  Children  rated  in  Accordance  with  School 
Standards  as  being  Three  Years  below  their  Grades. 


Retarded. 

At  Age. 

Ad- 

5 Yrs. 

4  Yrs. 

3iYrs. 

3  Yrs. 

21  Yrs. 

1 

2  Yrs. 
2 

1  Yr. 
4 

vanced. 

1 

1 

3 

2 

0 

0 

1547  School  Children,  for  the  Most  Part  American, 
selected  at  Random. 


w 

('tan 

led. 

At 
Age. 

Advanc(Hl. 

H 

0 

t 

8 

CO 

79 

15(1 

312 

CO 
14 

1 

37 

329 

49 

'  Kindly  fnrnisli(>(l  by  Dr.  Henry  H.  Goddard  of  The  Training 
School  for  Backward  and  Fcehle-ininded  Children  at  Vineland, 
N.J. 


THE   PRACTICE  OF  PSYCHIATRY.  151 

It  should  be  mentioned  that  many  objections  have 
been  raised  to  the  Binet-Simon  tests,  some  of  which 
are  directed  more  against  their  careless  or  inexpert 
use  than  against  the  principles  on  which  they  are 
based.  On  the  other  hand  some  inherent  weaknesses 
have  also  been  discovered,  and  many  modifications 
of  the  tests  have  been  developed  intended  to  im- 
prove them.  Perhaps  the  most  interesting  modi- 
fication is  that  of  Yerkes  and  his  collaborators.^ 

§  5.   Examination  for  Aphasia. 

Cases  of  organic  brain  disease  with  lesions  in- 
volving the  speech  areas  and  therefore  presenting 
symptoms  of  aphasia  require  a  special  method  of 
examination.  An  outline  for  guidance  in  such  ex- 
aminations was  prepared  by  Professor  iVdolf  Meyer 
some  time  ago  for  use  in  the  New  York  state  hospital 
service.  It  is  here  reproduced  without  essential 
change. 

The  examination  presupposes  a  knowledge  of  the 
previous  educational  level  of  the  patient  and  a  com- 
plete neurological  status,  especially  accurate  tests  of 
hearing,  vision,  and  other  senses.  Never  omit  the 
question  whether  the  patient  is  right  or  left  handed. 
Give  a  general  description  of  the  mental  condition 
of  the  patient  and  his  attitude  towards  his  needs  and 
the  surroundings,  the  extent  of  attention  and  spon- 
taneity, his  general  appreciation  of  the  condition 
and  of  the  purpose  of  the  examination. 

^  Yerkes,  Bridges  and  Hardwick.  A  Point  Scale  for  Measuring 
Mental  Ability.     Baltimore,  1915. 


152  MANUAL  OF  PSYCHIATRY. 

Reaction  to  words  heard:  Does  the  patient  under- 
stand his  own  or  others'  names,  simple  or  compH- 
cated  words,  orders  (button  the  vest,  open  the 
mouth,  show  the  tongue,  touch  your  nose,  open  the 
window,  hold  up  three  fingers)?  Can  he  compose 
words  spelled  to  him?  Does  he  pay  attention?  Does 
he  depend  upon  gestures?  How  does  he  react?  (By 
repeating  the  words;  by  forming  the  question;  by 
adequate  answers  in  words  or  gestures?  Or  are  the 
reactions  inadequate,  paraphasic,  mere  action,  irrele- 
vant productions,  or  gibberish?)  Are  there  circum- 
locutions? Evasions  of  difficult  words,  or  sticking 
to  words?  Does  the  patient  pick  out  and  handle 
correctly  objects  named? 

Reactions  to  things  heard:  Does  the  patient  under- 
stand such  sounds  as  the  mewing  of  a  cat,  barking, 
ticking  of  watch,  jingling  of  keys  (tests  being  made 
with  his  eyes  shut)?  Is  the  intonation  of  question, 
scolding,  etc.,  understood? 

Repetition  of  words  and  sentences:  Is  the  meaning 
understood  at  once  or  only  after  repetition,  or  not 
understood  notwithstanding  repetition?  Is  there 
automatic  echolalia? 

Spontaneous  speech:  (a)  Have  the  patient  give  an 
account  of  the  onset  of  the  trouble,  of  his  admission 
to  the  hospital,  and  of  his  j)rcsent  coiidition.  Note 
to  what  extent  ho  volunteers  speech,  opens  or  con- 
tinues conversation,  and  sum  uj)  the  defects  of 
s])eech  shown  during  those  and  subsot^uont  tests. 
What  is  th(!  extent  of  his  vocabulary?  If  })ossible 
secure  a  stenographic  example,  (h)  Reciting  the 
ali)habet,   days  of  the  week,   months  of  the  year, 


THE  PRACTICE  OF  PSYCHIATRY.  153 

counting  from  one  to  twenty,  forward  and  back- 
ward, with  or  without  help,  (c)  Calculations. 
(d)  Reciting  the  Lord's  prayer,  a  poem,  (e)  Spell- 
ing words,  counting  words  and  syllables.  (/)  For- 
eign languages. 

Reaction  to  things  seen:  Can  the  patient  name 
coins,  key,  ring,  knife,  button,  thread,  bottle;  wool, 
cotton,  and  silk  in  various  colors;  a  book;  geometri- 
cal figures;  the  meaning,  forms,  and  colors  of  pic- 
tures? Does  he  understand  the  meaning  of  move- 
ments such  as  fiddling,  shooting,  gestures  of  threat 
and  beckoning?  Is  the  mimic  ai^preciation  disturbed 
(see  also  intonation)? 

Reaction  to  things  smelted:  Can  the  patient  notice 
and  name  odors  and  identify  them  (wintergreen, 
clove,  peppermint),  or  point  to  the  name  on  a  list, 
or  when  mentioned? 

Reaction  to  things  tasted:  Sugar,  salt,  quinine, 
noticed,  named,  or  picked  out  from  a  list,  or  when 
mentioned? 

Reaction  to  things  felt  (with  eyes  shut) :  Recogni- 
tion and  naming  of  objects  (right  and  left  hand); 
writing  on  the  skin  (hand  and  forehead,  geometrical 
figures,  numbers,  words).  Writing  movements  with 
the  flaccid  hand. 

Reaction  to  words  seen,  reading:  (a)  Printed  letters, 
short  and  long  words,  newspaper  headings,  para- 
graphs; does  the  patient  spell  them,  read  them  in 
syllables,  or  as  a  whole?  Does  he  pronounce  cor- 
rectly and  does  he  understand?  (6)  Abbreviations 
(W.  C.  T.  U.,  Y.  M.  C.  A.,  G.  A.  R.,  U.  S.  A.). 
(c)    Written    cards    (orders,    questions) ;     numerals 


154  MANUAL  OF  PSYCHIATRY. 

(Arabic,  Roman,  fractions,  multiplication),  (d)  The 
patients  own  writing;  name,  etc. 

Is  the  sense  grasped  without  speaking  what  is 
read,  or  only  from  reading  it  aloud?  Does  the 
patient  fumble  with  his  hands?  Speak  without 
grasping  the  sense?  Are  the  helps  of  any  use,  such 
as  tracing  the  letter  with  a  pencil  or  finger,  or  by  ex- 
tensive movements  of  the  hands  and  arms?  Is  there 
much  clinging  to  previously  spoken  words?  Is  there 
any  improvement  by  repetition  and  by  helping 
along? 

Writing:  (a)  Spontaneous,  a  letter  to  a  friend  with 
signature,  or  a  statement  concerning  present  con- 
dition. Describe  the  effort,  (b)  Writing  from  dic- 
tation: name,  sentences,  numerals,  abbreviations 
(Y.  M.  C.  A.,  etc.).  (c)  Calculations  in  writing. 
(d)  Copying  written  or  printed  words  and  sentences. 
Does  the  patient  understand  what  he  copies?  Copy- 
ing unfamiliar  characters,  such  as  Greek  or  Hebrew. 

Drawing:  Triangle,  circle,  tree,  automobile;  copy- 
ing. 

Music:  Is  singing  and  playing  understood?  Can 
a  tone  be  taken  correctly?  Can  the  patient  play  or 
sing?  Sing  a  tune  with  the  words?  Speak  the 
words  without  the  tune?  Can  he  read  notes?  Write 
notes  (from  memory  or  copy)? 

Mimic  and  gestures:  To  what  extent  understood 
and  used? 

Internal  language:  Is  the  memory  of  places  and 
topography  motor  or  visual?  Are  forms  remembered 
by  motion  or  visually?  Can  the  patient  sound 
words  mentally?     Remember  the  faces  of  friends? 


THE  PRACTICE  OF  PSYCHIATRY.  155 

Color  of  things,  visually  or  only  by  word  association? 
As  a  rule  conclusions  must  be  drawn  from  the  gen- 
eral composure,  adaptability,  attention;  the  indi- 
cations of  the  number  of  letters  or  syllables  in  a 
word;  playing  with  cards,  counting  out  every  sixth 
card,  etc.     Does  the  patient  reason? 

Apraxia:  Use  of  objects,  etc. 

Analysis  of  jparaphasic  symptoms:  Is  the  patient 
aware  of  the  difficulty?  Is  he  apathetic  or  indiffer- 
ent, or  making  efforts  to  correct  himself,  or  to 
substitute? 

§  6.   Association  Tests. ^  —  Other  Tests. 

Association  tests  may  be  found  useful  in  studying 
disturbances  of  flow  of  thought;  they  afford  a  means 
of  measuring  mental  capacity  somewhat  like  the 
Binet-Simon  tests;  and  they  have  been  used  for  the 
detection  of  subconscious  ideas  or  complexes.  For 
whatever  object  employed,  it  would  seem  advisable 
to  make  use  of  a  standardized  procedure;  for  this 
reason  the  test  developed  by  Kent  and  Rosanoff  is 
recommended. 

The  technique  of  the  test  is  very  simple.  One 
uses  a  sheet  with  the  stimulus  words  printed  on  it 
and  with  space  opposite  each  stimulus  word  for  the 
reaction.  In  a  room  reasonably  free  from  distracting 
influences  the  subject  is  seated  at  a  distance  from 

1  G.  Aschaffenburg.  Experimentelle  Sludien  iiber  Associationen. 
Kraepelin's  Psychologische  Arbeiten,  Vols.  I,  II,  and  lY.  —  C.  G. 
Jung.  Diagnostiache  Associaziationsstudien.  —  Kent  and  Rosanoff. 
A  Study  of  Association  in  Insanity.  Amer.  Journ.  of  Insanity,  July 
and  Oct.,  1910. 


156 


MANUAL  OF   PSYCHIATRY. 


the  experimenter  so  as  to  be  unable  to  see  either 
the  printed  stimulus  words  or  the  reactions  as  they 
are  being  recorded.  He  is  instructed  to  respond  to 
each  stimulus  word  with  the  first  word  that  comes  to 
his  mind  other  than  the  stimulus  word  itself  or  a 
mere  different  grammatical  form  of  it,  to  respond 
with  one  word  only  and  not  with  a  compound  word 
or  a  sentence  or  phrase.  A  few  stimulus  words  not 
on  the  list  may  be  given  for  preliminary  practice, 
the  reactions  not  being  recorded;  and  when  it  ap- 
pears that  the  subject  understands  the  instructions 
the  test  may  be  begun.  Should  the  subject  in  the 
course  of  the  test  give  an  unacceptable  reaction,  it 
is  not  put  down,  but  the  pertinent  instruction  is  re- 
peated, the  test  continued,  and  at  the  end  all  the 
stimulus  words  thus  improperly  reacted  to  and 
therefore  remaining  without  a  recorded  reaction  are 
given  over  again.  The  following  are  the  stimulus 
words  used  in  the  Kent-RosanofT  test. 


1. 

table 

17. 

butterfly 

.33. 

foot 

49. 

eagle 

2. 

dark 

18. 

smooth 

.34. 

spider 

50. 

stomach 

3. 

mu.sic 

19. 

conunand 

35. 

needle 

51. 

stem 

4. 

sickness 

20. 

chair 

36. 

red 

52. 

lanif) 

5. 

man 

21. 

sweet 

37. 

sleep 

53. 

dream 

(). 

deep 

22. 

whistle 

38. 

anger 

54. 

yellow 

7. 

.soft 

23. 

woman 

39. 

carpet 

55. 

bread 

S. 

catini^ 

24. 

cold 

40. 

girl 

56. 

justice 

9. 

mountain 

25. 

slow- 

41. 

high 

57. 

bov 

10. 

hou.sc 

20. 

wish 

42. 

working 

58. 

ligiit 

11. 

black 

27 

river 

43. 

sour 

59. 

health 

12. 

mutton 

28. 

white 

44. 

earth 

00. 

Bible 

1.:!. 

comfort 

29. 

beautiful 

45. 

trouble 

01. 

memory 

14. 

hand 

30. 

window 

40. 

soklier 

62. 

sheep 

15. 

short 

31. 

rouiih 

47. 

cabbage 

63. 

bath 

16. 

fruit 

32. 

citizen 

48. 

hard 

64. 

cottage 

THE   PRACTICE  OF   PSYCHIATRY. 


157 


65. 

swift 

74. 

whiskey 

83. 

loud 

92. 

scissors 

66. 

blue 

75. 

child 

84. 

thief 

93. 

quiet 

67. 

hungry 

76. 

bitter 

85. 

lion 

94. 

green 

68. 

priest 

77. 

hammer 

86. 

joy 

95. 

salt 

69. 

ocean 

78. 

thirsty 

87. 

bed 

96. 

street 

70. 

head 

79. 

city 

88. 

heavy 

97. 

king 

71. 

stove 

80. 

square 

89. 

tobacco 

98. 

cheese 

72. 

long 

81. 

butter 

90. 

baby 

99. 

blossom 

73. 

religion 

82. 

doctor 

91. 

moon 

100. 

afraid. 

This  test  has  been  appUed  by  Kent  and  Rosanoff 
to  one  thousand  normal  subjects,  and  all  reactions 
thus  obtained  arranged  in  frequency  tables  for  all  the 
stimulus  words;  these  frequency  tables  were  pub- 
lished in  connection  with  their  study.  In  the  ex- 
amination of  a  test  record  obtained  by  this  method 
the  first  step  is  to  compare  it  with  the  frequency 
tables  and  thereby  distinguish  the  common  reactions, 
which  are  to  be  found  in  the  tables  and  which  are  for 
the  most  part  normal,  from  individual  reactions, 
which  are  not  to  be  found  in  the  tables  and  which 
contain  the  great  majority  of  those  that  are  of 
pathological  significance.  Normal  subjects  seldom 
give  over  10%  individual  reactions;  insane  subjects 
very  often  give  over  25%.  Moreover,  certain  va- 
rieties are  to  be  distinguished  among  the  individual 
reactions  which  are  more  or  less  characteristic  of  the 
various  clinical  types  of  mental  disorder. 

Standards  have  also  been  made  available  for  the 
ages  of  childhood  from  4  to  15  years. ^  Feeble- 
mindedness is  recognizable  with  the  aid  of  this  test, 
and  its  degree  may  be  roughly  determined  by  refer- 


1  Isabel  R.  and  A.  J.  Rosanoff.   A  Study  of  Association  in  Children. 
Psychol.  Review,  Jan.,  1913. 


158  MANUAL  OF  PSYCHIATRY. 

ence  to  the  standards  for  normal  children.^  The 
results  of  this  test  are  by  no  means  always  conclusive, 
for  many  cases  of  frank  mental  disorder  have  fur- 
nished practically  normal  records;  on  the  other 
hand,  it  is  sometimes  capable  of  revealing  mental 
abnormality  where  other  methods  of  examination 
yield  only  negative  results. 

In  cases  in  which  it  is  desired  to  use  the  association 
test  for  the  purpose  of  detecting  pathogenic  subcon- 
scious ideas  or  complexes  that  may  be  suspected  to 
exist,  the  examiner's  familiarity  with  the  case  will 
suggest  to  him  special  stimulus  words  adapted  to 
the  particular  case;  these  stimulus  words  may  be 
given  together  with  those  regularly  employed,  being 
introduced,  say,  after  every  fifth  or  every  tenth  one. 
In  such  cases  it  is  also  advisable  to  record  in  each 
instance  the  reaction  time  in  fifths  of  a  second, 
taken  by  means  of  a  stop  watch;  subconscious  ideas 
or  complexes  are  said  to  be  indicated  either  by  ab- 
normal types  of  reaction  or  by  instances  of  reaction 
time  much  above  the  average  for  the  individual. 

Other  tests.-  —  Many  other  tests,  both  physical 
and  mental,  have  been  more  or  less  thoroughly 
standardized  and  are  available  both  for  clinical  work 
and  for  psychiatric  research:  weight  discrimination 
tests,  calculation  tests,  cancellation  tests,  substi- 
tution tests,  etc.  For  descriptions  of  these  the 
student  must  be  n^foi-nMl  to  special  works. 

^  Ljiustman  and  Rtx'^anofT.  Asmridtion  in  Fahli-mindcd  and 
Dvlin'jucnt  Children.     Aiiht.  Jouni.  of  Insanity,  July,  1912. 

-  CJ.  M.  Whii)i)l('.  Mninuil  of  Mnital  and  Physical  Tests.  Second 
edition.  Baltimore,  1915.  —  Woodworth  and  Wells.  Association 
Tests.  The  Psychol.  Monographs,  No.  57,  Dec,  1911.— S.  I. 
Franz.  Handbook  of  Mental  Examination  Methods.  Nerv.  and 
Ment.  Dia.  Monogr.  Series,  No.  10.     New  York,  1912. 


CHAPTER  VII 

THE  PRACTICE  OF  PSYCHIATRY   (Continued). 

GENERAL  THERAPEUTIC  INDICATIONS:  INSTITUTION. 
—  COMMITMENT.  — TREATMENT  OF  EXCITEMENT, 
OF  SUICIDAL  TENDENCIES,  AND  OF  REFUSAL  OF 
FOOD.  —  PSYCHOTHERAPY.  —  PAROLE  AND  DIS- 
CHARGE. —  AFTER-CARE. 

There  is  no  general  treatment  for  all  mental 
affections  any  more  than  there  is  for  all  affections  of 
the  stomach  or  kidneys.  Certain  therapeutic  indi- 
cations, however,  are  of  such  importance  and  arise 
so  often  that  it  will  be  advisable  to  make  a  general 
study  of  them. 

Some  pertain  to  the  surroundings  in  which  patients 
should  be  placed,  others  to  certain  particularly  grave 
manifestations  of  mental  affections:  excitement, 
suicidal  tendencies,  and  refusal  of  food. 

Surroundings ;  institution ;  commitment.  —  In  most 
of  the  psychoses  it  is  necessary  to  secure  for  the 
patient  complete  physical  and  mental  rest  and  to 
relieve  him  as  far  as  possible  from  his  preoccupa- 
tions, delusional  or  rational. 

It  is  difficult  to  carry  out  these  indications  in  the 
ordinary  conditions  of  life.  The  difficulties  are  of  a 
nature  both  physical  and  mental:  physical,  because 
only  few  families  can  afford  the  expense  involved  in 
the  treatment  of  an  insane  patient  at  home;    and 

159 


160  MANUAL  OF  PSYCHIATRY. 

mental,  because  the  relatives,  inexperienced  in  the 
treatment  of  mental  diseases,  are  not  likely  to  carry 
out  properly  all  the  orders  of  the  physician,  and 
may  cause  an  aggravation  of  the  patient's  condition 
by  yielding  to  all  his  caprices,  being  under  the  im- 
pression that  he  must  not  be  contradicted,  and  by 
wear>ang  him  in  their  attempts  to  reason  with  him 
or  to  divert  his  mind. 

The  removal  to  an  institution  is  therefore  in  most 
cases  inevitable. 

All  insane  patients  may  be  grouped  in  two  classes: 
the  inoffensive  and  the  dangerous. 

For  the  first  class  of  cases  the  institution  does  not 
present  any  particular  features  and  the  admission  of 
the  patient  is  effected  with  no  more  formality  than 
that  into  a  general  hospital. 

The  patients  of  the  second  class  must  be  committed; 
this  must  be  accomplished  under  the  supervision  and 
responsibility  of  a  public  authority,  and  entails 
certain  formalities. 

Of  all  these  formalities  only  one  is  of  interest  to 
us  here:   the  physician's  certificate. 

The  certificate,  intended  to  establish  the  legitimacy 
of  the  commitment,  need  not  contain  any  detailed 
observations  and  does  not  necessarily  involve  a  pre- 
cise clinical  diagnosis.  It  is  of  little  importance  here 
whether  the  patient  does  or  does  not  present  in- 
equality of  the  pupils  or  abolition  of  the  patellar  re- 
flexes. It  is  also  uninijiortant  whether  he  suffers 
from  mania  or  from  dementia  pnecox,  as  long  as  the 
symptoms  which  he  presents  rend(U'  him  a  menace 
to  himself,  to  others,  or  to  the  public  peace. 


THE  PRACTICE  OF  PSYCHIATRY  161 

The  indications  for  commitment  are  chiefly  to  be 
based  on  the  dangerous  tendencies  of  the  patient :  a 
senile  dement  who  is  quiet  and  tractable  can  without 
any  inconvenience  be  cared  for  at  home  or  in  a  home 
for  the  aged ;  another  who  is  on  the  contrary  irritable 
and  violent  should  be  committed  without  hesitation. 

In  a  general  way  the  following  symptoms  should  be 
considered  as  indications  for  commitment:  im- 
pulsive tendencies;  suicidal  ideas;  ideas  of  persecu- 
tion and  hallucinations  which  bring  about  violent 
reactions;  states  of  dementia  associated  with  phe- 
nomena of  excitement. 

The  character  and  intensity  of  the  symptoms 
should,  however,  not  be  the  only  factors  governing 
the  action  of  the  physician.  He  should  also  take  into 
account  their  probable  duration.  If  the  mental  dis- 
order is  not  likely  to  persist  for  more  than  several 
days  and  has  no  tendency  to  recur  frequently,  com- 
mitment is  not  justifiable;  such  is  the  case  in  febrile 
deliria. 

Transfer  of  the  patient  to  the  institution.  —  Un- 
doubtedly it  is  the  physician's  duty  to  induce  the 
patient  to  go  to  a  hospital.  Unfortunately  this  is  not 
always  easy  or  even  possible  when  the  question  is  one 
of  commitment.  This  question,  at  times  delicate, 
cannot  of  course  have  a  universal  solution. 

TREATMENT    OF    EXCITEMENT. 

Perhaps  the  greatest  progress  in  the  therapeutics 
of  mental  diseases  within  the  past  twenty  years  has 
been  in  our  methods  for  the  treatment  of  excite- 
ment. 


162  MANUAL  OF  PSYCHIATRY. 

By  degrees,  means  of  restraint,  always  useless, 
often  barbarous,  have  disappeared  from  institutions. 

The  honor  of  having  introduced  into  France  non- 
restraint,  or  treatment  of  excitement  without  me- 
chanical restraint,  belongs  to  Magnan  (1867). 

The  methods  employed  to-day  in  combating  ex- 
citement may  be  grouped  under  four  principal  heads : 

Rest  in  bed; 

Hydrotherapy; 

Isolation ; 

Medication. 

Rest  in  bed.^ — First  used  in  melancholia  (Guislain, 
Griesinger,  Ball),  rest  in  bed  has  been  only  recently 
adopted  in  the  treatment  of  excitement.  Magnan 
has  introduced  its  use  into  France,  after  having 
shown  the  excellence  of  its  effects  and  the  relative 
facility  of  its  employment. 

Rest  in  bed  presents  the  triple  advantage  of  saving 
the  patient's  strength,  cahning  excitement,  and  facilitat- 
ing supervision.  It  is  indicated  in  most  of  the  acute 
psychoses  and  in  the  periods  of  exacerbation  of 
chronic  psychoses.  Rest  in  bed  need  not  necessarily 
be  constant  to  be  efficacious,  except  in  cases  in  which 
the  gravity  of  the  general  condition  requires  it.  It 
is  well  to  allow  j)atients  to  get  up  for  two  or  three 
hours  daily,  using  part  of  the  time  for  outdoor  walks, 
the  duration  of  which  is  to  be  determined  by  the 
special  indications  in  each  case. 

Rest  in  bed  produces  the  l)cst  effects  when  carried 
out  collect i\'ely  in  small  dormitories  containing  not 

'  Pochon.  These  do  Paris,  1899.  —  Wizol.  Ann.  med.  psych., 
1901.  —  S6rieux  et  Farnarier.     Ann.  med.  psych.,  1900. 


THE  PRACTICE  OF  PSYCHIATRY.  163 

more  than  ten  beds.  The  example  of  patients  who 
have  akeady  submitted  to  this  mode  of  treatment 
exercises  a  salutary  influence  upon  newcomers  and 
helps  to  induce  them  also  to  accept  it.  Under  favor- 
able conditions  two  or  three  days  generally  suffice 
for  even  a  very  excited  maniac  to  become  accustomed 
to  staying  in  bed,  and  to  become  calmed  to  a  certain 
extent. 

Though  he  may  still  persist  in  restless  movements, 
he  rarely  leaves  his  bed,  and  when  he  does,  he  will 
return  without  difficulty  upon  the  simple  injunction 
of  the  nurse. 

Hydrotherapy.  —  The  cold  douche,  formerly  much 
employed  for  calming  excitement,  acts  chiefly  by 
its  asphyxiating  effect.  It  is  therefore  not  surpris- 
ing that  it  has  been  entirely  abolished. 

Of  the  various  forms  of  hydrotherapy  two  are 
most  frequently  used:  the  wet  pack  and  the  con- 
tinuous warm  bath. 

The  ivet  pack  is  apphed  by  means  of  a  sheet 
soaked  in  cold  water  and  closely  wrapped  around 
the  entire  body.  Its  duration  varies  from  twenty 
minutes  to  several  hours.  If  too  much  prolonged 
it  may  cause  attacks  of  syncope. 

Continuous  warm  baths  are  of  great  service  when 
rest  in  bed  does  not  suffice  to  calm  the  patient.  As 
generally  used  their  duration  does  not  exceed  five  or 
six  hours  daily.  Some  physicians,  however,  have  ob- 
tained good  results  from  the  permanent  warm  bath: 
the  patient  remains  in  the  bath  for  days  or  weeks. ^ 

1  Serieux.  Le  traitement  des  etats  d'agitation  par  le  bain  per- 
manent.    Revue  de  Psychiatrie,  Feb.,  1902. 


164  MANUAL  OF  PSYCHIATRY. 

Most  alienists  have  abandoned  the  old-fashioned 
covered  bath-tubs  intended  to  imprison  the  patient. 
If  necessary  he  is  simply  kept  in  by  several  nurses 
until  the  calming  effect  of  the  bath  becomes  ap- 
parent. 

Isolation.'  —  Much  opposed  of  late,  isolation 
presents,  in  fact,  certain  inconveniences,  the  gravest 
of  which  is  leaving  the  patient  by  himself  without 
constant  supervision;  it  is  absolutely  contrain- 
dicated  in  patients  with  suicidal  tendencies,  and 
should  not,  as  a  rule,  be  employed  until  the  other 
measures,  —  rest  in  bed  and  prolonged  baths,  — ■ 
have  been  tried. 

Nocturnal  isolation  consists  in  allowing  the  patient 
to  sleep  in  a  separate  room  which  should,  of  course, 
be  conveniently  accessible  to  the  attendant;  it  is  of 
great  utility  for  certain  chronic  disturbed  patients. 
Many  a  dement  who  makes  a  great  deal  of  noise 
during  the  night  in  the  domiitory  will  rest  quietly 
when  he  is  alone. 

Medication.  —  I  shall  limit  myself  to  the  mention 
of  those  drugs  which  are  most  frequently  used  in 
states  of  excitement,  and  shall  give  several  fonnula?. 

Opium  in  all  its  foniis  is  used  for  the  insane:  ex- 
tract of  opium  in  pills,  aqueous  solutions  of  morphine 
for  subcutaneous  injections,  tincture  of  opium,  etc. 

The  danger  of  forming  the  habit  prevents  the  use 
of  morphine  in  cases  reciuiring  prolonged  treatment. 

Chloral  enjoys  a  merited  reputation.  It  is  ad- 
ministered  in   solution   by  the   mouth   in    doses   of 

'  Mcrckliii.  I'cbcr  die  Anwendung  der  Isolicrunq  bci  dcr  Bchand- 
lung  Gtideskrankcr.     Allg.  Zoitschr.  f.  Paychiat.,  1903,  No.  6. 


THE  PRACTICE  OF  PSYCHIATRY.  165 

from  one  to  two  grams,  or  per  rectum  in  doses  of 
from  two  to  three  grams. 

Chloral  hydrate 1  or  2  grams 

Syrup  of  currant-berries 30  c.c. 

Water,  enough  to  make 60  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  hydrate 3  grams 

Yolk  of  egg 1 

Milk 120  c.c. 

To  be  administered  per  rectum,  preceded  by  a  simple  enema. 

Chloral  may  be  combined  with  bromides: 

Chloral  hydrate 1.5  grams 

Potassium  bromide 2  grams 

Syrup  of  currant-berries 30  c.c. 

Water,  enough  to  make 80  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  should  be  absolutely  prohibited  in  cases 
of  heart  disease. 

Bromides  may  also  be  used  alone  in  doses  of  from 
two  to  four  grams. 

Sulphonal,  trional,  and  tetronal  bring  about  calm 
and  prolonged  sleep  in  cases  of  moderate  excite- 
ment, given  in  doses  of  one  or  two  grams.  They  are 
usually  administered  in  powders  each  containing  one 
gram  of  any  one  of  these  hypnotics.  One  or  two 
such  powders,  according  to  the  case,  is  to  be  ad- 
ministered in  the  evening  towards  six  o'clock,  the 
action  of  these  drugs  being  slow. 


166  MANUAL  OF  PSYCHIATRY. 

Chloralose,  hypnal,  and  somnal  may  also  be  of 
service. 

Chloralose 20  to  60  centigrams 

Given  in  ;i  powder. 

Ilypiuvl 2  grams 

Chloroform-water 100  c.c. 

Syrup  of  peppermint 30  c.c. 

To  he  administered  in  two  or  three  doses  hy  the  mouth.     (Debove 
and  Gourin.) 

Somnal 2  grams 

Syrup  of  currant-berries 40  c.c. 

Water 20  c.c. 

To  be  administered  like  the  preceding.     (Debove  and  Gourin.) 

Paraldehyde  may  be  given  by  the  mouth,  by  the 
rectum,  or  hypodennically  in  doses  of  from  2  to  5 
grams.  It  is  an  excellent  hj^Dnotic.  Its  only  in- 
convenience is  the  disagreeable  and  persistent  odor 
which  it  imparts  to  the  breath. 

Paraldehyde* 2  to  5  grama 

Rum 20  c.c. 

Lemon-juice l.o  c.c. 

Simple  syrup 30  c.c. 

Distilled  water 40  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth.     (Debove 
and  Gourin.) 

ParaUlehyde 4  grams 

^'olk  of  egg 1 

Milk 120  c.c. 

To  be  administered  in  one  dose  per  rectum,  preceded  by  a  simple 
enema. 


THE   PRACTICE  OF  PSYCHIATRY.  167 

Hyosdne  hydrobromate  or  hydrochlorate  is  a  very 
active  drug  and  must  be  used  with  great  caution. 
It  may  be  administered  in  solution,  in  pills,  or  by 
subcutaneous  injection. 

Hydrochlorate  of  hyoscine 0 .  005  gram 

Syrup  of  peppermint 30  c.c. 

Water  enough  to  make 120  c.c. 

A  tablespoonful  every  ten  minutes  until  four  doses  have  been  given.' 

Hyoscine  hydrobromate 0 .  02  gram 

Water 20  grams 

For  subcutaneous  injection. 

One  ordinary  hypodermic  syringeful  contains  two 
milligrams  of  the  drug.  Half  a  syringeful  is  given  at 
first;  it  is  very  rare  that  the  sedative  effect  is  not 
produced  by  a  whole  syringeful. 

SUICIDAL   TENDENCIES. 

Suicide  among  the  insane  is  perhaps  the  greatest 
source  of  anxiety  to  the  practical  psychiatrist.^ 

All  the  forms  of  mental  alienation,  excepting  per- 
haps mania,  may  give  rise  to  ideas  of  suicide,  but 
the  first  place  from  this  standpoint  belongs  to  psy- 
choses of  the  depressed  form  (involutional  melan- 
cholia, depressed  form  of  manic  depressive  insanity, 
certain  forms  of  alcoholism,  etc.). 

WTiatever  the  nature  of  the  disease  may  be,  ideas 
of  suicide  may  result: 

(a)  From  an  imperative  hallucination :  a  voice 
calls  the  patient  to  heaven,  orders  him  to  die  in 
atonement  for  his  sins,  etc. ; 

1  Viallon.     Suicide  et  folic.     Ann.  med.  psych.,  1901. 


168  MANUAL  OF  PSYCHIATRY. 

(b)  From  a  delusion:  fear  of  death  from  starva- 
tion, of  being  afflicted  with  an  incurable  disease; 
some  patients  commit  suicide  to  escape  the  imaginary- 
persecutions  of  their  enemies; 

(c)  From  an  unconquerable  disgust  for  existence 
(tcedium  vitcc)  or  from  an  intolerable  psychic  pain; 

{d)  From  a  sudden  impulse  (catatonia) ; 

(e)  From  a  suggestion:  family  suicide,  epidemics 
of  suicide; 

(/)  From  a  fixed  idea,  the  origin  of  which  is  in- 
explicable. Such  is  the  case  reported  by  Ferrari: 
An  officer  declared  on  several  occasions  that  it  was 
ridiculous  to  live  beyond  sixty  years.  On  the  last 
day  of  his  sixtieth  year,  after  having  passed  a  merry 
evening  with  his  friends,  he  announced  his  intention 
of  committing  suicide.  He  went  into  his  room  and 
shot  himself  with  a  revolver. 

The  smallest  objects  may  become  in  the  hands 
of  patients  deadly  weapons  which  they  may  turn 
against  themselves.  Magnan  reported  a  case  of  a 
melancholiac  who  perforated  his  heart  by  means  of  a 
needle  measuring  scarcely  3  centimeters  in  length. 
Some  patients  at  times  resort  to  procedures  so  hor- 
rible that  their  use  cannot  be  explained  otlierwise 
than  by  the  existence  of  marked  anaesthesia;  thus  a 
patient  of  Baillarger's  applied  his  forehead  to  a  red- 
hot  plate  of  iron. 

In  institutions,  where  the  patients  are  not  allowed 
to  have  in  their  possession  any  dangerous  instru- 
ments, the  means  most  frequently  made  use  of  is 
hanging,  which  fact  is  explained  by  the  extreme 
simplicity  of  the  procedure. 


THE  PRACTICE  OF  PSYCHIATRY.  169 

Together  with  suicide  may  be  classed  the  self- 
mutilations  which  patients  frequently  commit. 

Insane  patients  have  been  known  to  cut  off  their 
own  fingers,  lacerate  or  even  cut  off  their  genital 
organs  by  means  of  pieces  of  glass,  open  their  abdo- 
mens, etc. 

The  treatment  of  suicidal  tendencies  is  reduced  to 
strict  and  constant  watching,  which  should  be  insti- 
tuted as  soon  as  the  existence  of  such  tendencies  is 
suspected,  and  continued  for  a  long  time  after  their 
apparent  disappearance.  As  we  have  already  stated 
above,  isolation  is  absolutely  contraindicted.  Keep- 
ing the  patient  in  an  observation  ward  and  rest  in  bed 
during  the  acute  periods  are  very  useful  measures. 

EEFUSAL   OF   FOOD    (sITIOPHOBIA). 

Refusal  of  food  ^  may  result  from : 

(a)  Delusions  with  or  without  coexisting  halluci- 
nations: fear  of  being  poisoned  or  of  not  being  able 
to  digest  the  food;  hypochondriacal  ideas; 

(b)  The  desire  to  starve  to  death; 

(c)  An  unconquerable  disgust  for  food; 

(d)  Negativism  (catatonia,  general  paresis). 
Refusal  of  food  may  be  partial  or  complete.     Some 

patients  will  accept  only  certain  kinds  of  food,  often 
because  these  appear  to  them  to  be  the  safest  or  be- 
cause "the  voices"  order  them  so.  One  patient 
lived  solely  on  eggs,  the  shell  seeming  to  him  to  be 
the  only  impenetrable  barrier  to  the  mysterious 
agencies  used  by  his  persecutors.     One  precocious 

^  Pfister.  Die  Abstinenz  der  Geisteskranken  und  ihre  Dehandlung. 
Freiburg,  1899. 


170  MANUAL  OF  PSYCHIATRY. 

dement  would  take  no  nourishment  other  than  stale 
bread  because  a  voice  from  heaven  commanded  him 
to  do  penance  by  fasting. 

It  may  be  also  absolute  or  relative.  Often  with  a 
little  perseverance  one  may  persuade  a  melancholiac 
to  accept  a  sufficient  quantity  of  nourishment  in  a 
coiivenient  form.  Some  catatonics  refuse  what  they 
have  been  offered  and  several  minutes  later  devour 
their  neighbor's  meal  without  there  being  any  de- 
lusion to  explain  their  conduct.  Others  refuse  to 
eat,  but  when  food  is  placed  in  their  mouth  they 
swallow  it  without  trouble.  Many  even  submit  with 
the  best  grace  to  being  fed  with  a  spoon  or  with  a 
feeding  cup. 

When  refusal  of  food  threatens  to  have  a  bad 
effect  upon  the  health  of  the  patient,  as  is  shown  by 
loss  of  weight  determined  by  systematic  weighings, 
one  must  resort  to  forced  feeding  or  ''tube-feeding." 

Tube-feeding  may  be  accomplished  in  two  ways: 
by  the  mouth  and  by  the  nose. 

Tube-feeding  by  the  mouth  is  the  less  painful  and 
less  dangerous  procedure  for  the  patient  as  well  as 
the  more  convenient  one  for  the  physician. 

The  necessary  instruments  are  a  mouth-gag,  a 
stomach-tube,  and  a  funnel  of  glass  or  rubber. 

The  operation  itself  is  perfonned  in  four  stages: 

(1)  Opening  the  mouth; 

(2)  Introducing  the  tube  into  the  stomach; 

(3)  Attaching  the  funnel  to  the  tube  and  ascer- 
taining the  proper  penetration  of  the  tube  into  the 
stomach ; 

(4)  Introducing  the  licjuid  food. 


THE  PRACTICE  OF  PSYCHIATRY.  171 

The  first  stage  presents  several  difficulties  due  to 
the  resistance  of  the  patient,  which  is  at  times  very 
great.  However,  by  dint  of  patience  and  by  taking 
advantage  of  the  little  interstices  between  the  jaws  it 
is  usually  possible  to  accomplish  this. 

The  introduction  of  the  tube  is  usually  easy.  The 
end  entering  the  pharynx  sets  up  reflexly  the  move- 
ments of  deglutition,  so  that  the  instrument  of  itself 
enters  the  oesophagus.  A  gentle  push  suffices  to 
make  it  enter  the  stomach. 

Although  the  large  size  of  the  tube  renders  a  false 
passage  almost  impossible,  the  purpose  of  the  third 
stage  is  to  ascertain  that  the  tube  is  well  in  place  and 
has  not  entered  the  trachea.  Two  procedures  are 
used  to  make  sure  of  this :  auscultation  at  the  open- 
ing of  the  funnel  and  introduction  into  the  tube  of 
several  drops  of  pure  water.  If  the  noise  produced 
by  the-gases  of  the  stomach  is  heard,  and  if  the  water 
runs  down  freety,  the  tube  is  in  place  and  is  not  ob- 
structed. Other^vise  the  tube  must  be  withdrawn 
and  cleaned  and  the  operation  recommenced. 

The  liquid  nourishment  should  always  be  intro- 
duced at  a  low  pressure.  Its  composition  may  vary 
according  to  individual  cases.  Milk,  eggs,  beef- 
juice,  peptones,  or  vegetable  soups  usually  constitute 
the  basis. 

Tube-feeding  through  the  nasal  passages  presents 
several  inconveniences: 

(1)  It  is  painful; 

(2)  It  often  causes  irritation  and  inflammation  of 
the  nasal  mucosa; 

(3)  The  small  size  of  the  tube  renders  its  pene- 


172  MANUAL  OF  PSYCHIATRY. 

tration  into  the  larynx  liable  to  occur,  and  does  not 
allow  the  use  of  any  but  perfectly  liquid  food. 

This  method  of  feeding  should,  therefore,  not  be 
resorted  to  except  in  special  cases,  such  as  those  of 
buccal  affections  interfering  with  the  introduction  of 
the  tube  by  the  mouth.  In  such  cases  a  properly 
sterilized  nasal  tube  or  large  sized  catheter  is  used; 
its  end  is  lubricated  with  sterilized  vaseline,  and  the 
operation  is  then  accomplished  in  three  stages: 

1.  Introduction  of  the  tube  through  the  nasal 
fossse;  this  is  effected  without  difficulty.  No  force 
should  be  used;  one  nasal  fossa  may  be  found  to  be 
obstructed  owing  to  a  deviation  of  the  septum,  a 
growth,  or  swelling  from  any  cause:  the  tube  may 
then  be  introduced  through  the  other  nostril. 

2.  Passing  the  end  of  the  tube  through  the 
pharynx.  This  is  a  most  delicate  procedure.  Owing 
to  reflex  contractions  or  to  voluntary  efforts  on  the 
part  of  the  patient  the  tube  is  very  apt  to  become 
coiled  up  in  the  throat,  eventually  to  be  expelled  by 
way  of  the  mouth;  it  must  then  be  withdrawn  and 
the  operation  recommenced.  This  can,  in  a  meas- 
ure, be  prevented:  as  the  end  of  the  tube  enters  the 
pharynx  a  little  water  may  be  poured  (uther  into  the 
funnel  or  into  the  patient's  mouth;  this  starts  up 
movements  of  deglutition  by  which  the  end  of  the 
tube  is  directed  into  the  oesoj)hagus.  As  stated 
al)ove,  the  tube  may  enter  the  larynx  and  trachea: 
as  soon  as  that  hap])ons  all  groaning  and  talking  stops 
and  with  each  resj)iratory  act  air  rushes  in  and  out 
of  the  tube  with  a  sucking  and  })lowing  noise;  the 
tube  must  then  be  partly  withdrawn,  until  the  end 


THE  PRACTICE  OF  PSYCHIATRY.  173 

is  released  from  the  larynx.  This  is  not  so  apt  to 
occur  if  the  patient's  head  is  raised  by  two  pillows: 
in  that  position  the  direction  of  the  pharynx  is  more 
nearly  in  line  with  that  of  the  oesophagus,  whereas 
when  the  head  is  hyper-extended  the  direction  of  the 
pharynx  is  more  nearly  in  line  with  that  of  the 
larynx  and  trachea;  even  the  voluntary  act  of  swal- 
lowing is,  in  this  latter  position,  as  every  one  knows, 
difficult. 

3.  Descent  of  the  tube  down  the  oesophagus  and 
its  penetration  into  the  stomach.  The  small  size  of 
the  tube  renders  it  liable  to  being  expelled  by  an 
eflfort  of  vomiting.  This  does  not  happen  with  a 
stomach  tube  such  as  is  used  in  tube-feeding  by  the 
mouth.  By  using  a  tube  which  is  sufficiently  stiff 
this  can  usually  be  prevented. 

Not  infrequently  after  tube-feeding  the  patient  re- 
jects the  contents  of  the  stomach  either  spontane- 
ously or  by  a  voluntary  effort.  This  may  often  be 
prevented  by  throwing  a  few  drops  of  water  in  his 
face.  In  cases  of  obstinate  vomiting  the  irritability 
of  the  stomach  mucosa  may  be  diminished  by  in- 
troducing with  the  liquid  food  several  drops  of  a 
solution  of  cocaine. 

It  may  be  useful  to  precede  the  feeding  by  lavage 
of  the  stomach. 

PSYCHOTHERAPY. 

Psychotherapy  is  the  use  of  psychic  factors  in  the 
treatment  of  disease. 

The  essential  element  of  psychotherapy  is  sug- 
gestion.    Its  successful  practice  is  dependent  on  the 


174  MANUAL  OF  PSYCHIATRY. 

nature  of  the  disorder,  the  attitude  of  the  patient, 
and  the  personaUty  of  the  physician. 

The  so-called  psycho-neuroses  (hysterical,  neu- 
rasthenic, psychasthenic,  and  allied  disorders)  are 
most  amenable  to  psychic  treatment.  The  graver 
psychoses  are  much  less  readily  influenced. 

The  patient  must  have  full  confidence  in  the 
physician  and  in  his  methods.  ' '  The  nervous  patient 
is  on  the  path  to  recovery  as  soon  as  he  has  the  con- 
viction that  he  is  going  to  be  cured;  he  is  cured  on 
the  day  when  he  believes  himself  to  be  cured." ^ 

It  follows  that  the  physician  must  be  able  to  in- 
spire respect  and  trust.  According  to  Griesinger^  he 
must  have  "a  kind  disposition,  great  patience,  self- 
possession,  particular  freedom  from  prejudice,  an 
understanding  of  human  nature  resulting  from  an 
abundant  knowledge  of  the  world,  adroitness  in  con- 
versation, and  a  special  love  of  his  calling." 

As  to  the  manner  of  employing  suggestion  the  in- 
dications must  be  sought  in  the  individual  case.  In 
some  cases,  the  patient's  faith  being  strong,  a  mere 
statement  that  the  symptoms  are  quickly  disap- 
pearing may  be  sufficient.  In  other  cases  "rational" 
suggestion  with  an  explanation  of  the  cause  of  the 
sjanptoms  and  of  the  best  means  of  combating  thorn 
is  more  effective  ''There  is  a  great  differoiico  in 
mentality  between  the  man  who  is  content  with  a 
statement,  who  allows  hhnself  to  be  under  the  in- 

•  Paul  Dubois.  The  Psi/chic.  Trvaintcnl  of  Nervous  Disorders. 
Eiifilish  translation  by  JcUifTc  and  White.  Funk  and  Wagiialls 
Company,  New  York  and  London.  1905.     P.  210. 

"  Quoted  by  Ivraepelin.     Psychmtrie.     Seventh   edition.     Vol.  I. 


THE  PRACTICE  OF  PSYCHIATRY.  175 

fluence  of  the  personality  of  a  healer,  and  the  man 
who  acquires  confidence  by  the  clear  exposition  of 
the  reasons  to  believe."  ^  In  still  other  cases  hypnotic 
suggestion  affords  the  best  results. 

Special  mention  should  be  made  of  religious  in- 
fluences, which  are  of  extraordinary  efficacy  in  some 
cases.  Cures  produced  by  pilgrimages  to  shrines  or 
by  the  practice  of  Christian  Science  are  instances  in 
point.  Equally  striking  are  the  cures  of  habits  of 
intemperance  produced  by  religious  conversion  or, 
among  good  Catholics,  by  taking  the  pledge  of  total 
abstinence.  In  these,  as  in  other  measures  of  psy- 
chotherapy, the  active  principle  is  suggestion  and 
therefore  the  existence  of  strong  faith  is  a  condition 
necessary  for  success. 

Freud  2  has  called  attention  to  certain  psychogenic 
mechanisms  the  essential  feature  of  which  is  the 
repression  from  consciousness  of  memories  of  dis- 
agreeable experiences;  these  repressed  memories  or 
"complexes"  (Jung)  give  rise  to  parsesthesias,  pa- 
ralyses, states  of  anxiety,  obsessions,  hallucinations, 
delusions,  etc.  This  occurs  in  hysteria,  but  the  like- 
lihood of  such  mechanisms  being  at  work  in  dementia 
praecox,  some  paranoic  conditions,  certain  depressions, 
and  other  psychoses  as  well,  has  been  pointed  out.^ 

1  Paul  Dubois.     Loc.  cil.,  p.  227. 

*  S.  Freud.  Selected  Papers  on  Hysteria  and  Other  Psychoneu- 
roses.     (English  translation  by  A.  A.  Brill.) 

^  C.  G.  Jung.  The  Psychology  of  Dementia  Prcecox.  (English 
translation  by  Frederick  Peterson  and  A.  A.  Brill.)  —  A.  A.  Brill. 
A  Case  of  Schizophrenia.  Amer.  Journ.  of  Ins.,  July,  1909.  — 
Ernest  Jones.  Psycho-analytic  Notes  on  a  Case  of  Hypomania, 
Amer.  Journ.  of  Ins.,  Oct.,  1909. 


176  MANUAL  OF  PSYCHIATRY. 

This  view  of  the  genesis  of  certain  symptoms  has 
a  certain  bearing  upon  psychotherapy.  In  any  case 
in  which  the  existence  of  such  mechanisms  is  sus- 
pected it  becomes  necessary  for  the  physician  to  dis- 
cover the  pathogenic  complexes;  the  mere  discovery 
of  the  repressed  complexes  and  the  demonstration 
of  their  relation  to  the  symptoms  often  result,  in  the 
language  of  Freud,  in  psychic  "  catharsis  "  and  cure. 

This  is  accomplished  by  means  of  psychoanalysis, 
—  a  difficult,  time-robbing  task  requiring  skill  which 
comes  only  with  experience.  For  the  purpose  of 
psychoanalysis  four  methods  have  been  employed: 
(1)  direct  but  tactful  and  painstaking  interrogation 
in  repeated  confidential  interviews,  (2)  the  associa- 
tion test,^  (3)  analysis  of  dreams,^  (4)  interrogation 
in  the  hypnotic  state. 

In  cases  of  mental  deterioration  the  object  of 
psychotherapy  is  re-education,  not  with  the  hope  of 
bringing  about  recovery  but  with  that  of  training 
the  subject  to  do  some  simple  yet  productive  labor 
(basket  weaving^  mat  making,  chair  caning,  sewing, 
farm  labor,  etc.). 

Delusional  states  are  notoriously  refractor}^  to 
suggestion  or  reason.  Yet  in  selected  cases,  in 
which  the  delusional  system  is,  so  to  speak,  of  a 
parasitic  nature,  not  essentially  a  function  of  a  vicieus 
mental  organization,  something  may  be  accomplished 
when  a  favorable  opportunity  presents  itself  of  dem- 
onstrating to  the  patient  the  incorrectness  of  his 
belief. 

'  C  G.  JuHfj;.     Didgnostische  Assozialionsstudien. 
^  S.  Freud.     Die  Traumdculung. 


THE  PRACTICE  OF  PSYCHIATRY.  177 

I  shall  quote  from  the  recently  published  autobiog- 
raphy of  a  man  who  had  suffered  from  a  severe  and 
prolonged  attack  of  manic  depressive  insanity  from 
which  he  subsequently  recovered.^ 

This  man  had  developed  a  complex  system  of  delu- 
sions of  persecution  by  detectives.  Within  the  space 
of  a  fraction  of  a  minute  he  succeeded  in  fully  cor- 
recting all  his  false  ideas  when  he  found  convincing 
proof  that  he  whom  he  had  regarded  as  his  brother's 
double  and  a  detective  was  indeed  his  true  brother. 

"  I  dared  not  ask  for  ink,  so  I  wrote  with  a  lead  pencil.  Another 
fellow  patient  in  whom  I  had  confidence,  at  my  request,  addressed 
the  envelope;  but  he  was  not  in  the  secret  of  its  contents.  This  was 
an  added  precaution,  for  I  thought  the  Secret  Service  men  might 
have  found  out  that  I  had  a  detective  of  my  own  and  would  confiscate 
any  letters  addressed  by  him  or  me.  The  next  morning,  my  'detec- 
tive' (a  fellow  patient  who  had  the  privilege  of  going  and  coming 
unattended)  mailed  the  letter.  That  letter  I  still  have,  and  I 
treasure  it  as  any  innocent  man  condemned  to  death  would  treasure 
a  i)ardon  or  reprieve.  It  should  convince  the  reader  that  sometimes 
an  insane  man  can  think  and  write  clearly.  An  exact  copy  of  this  — 
the  most  important  letter  I  ever  expect  to  be  called  upon  to  write  — 
is  here  appended: 

August  29,  1902. 

"  Dear  George: 

On  last  Wednesday  morning  a  person  who  claimed  to  be  George 
M.  Beers  of  New  Haven,  Ct.,  clerk  in  the  Director's  Office  of  the 
Sheffield  Scientific  School  and  a  brother  of  mine,  called  to  see  me. 

"  Perhaps  what  he  said  was  true,  but  after  the  events  of  the  last 
two  years  I  find  myself  inclined  to  doubt  the  truth  of  everything  that 
is  told  me.  He  said  that  he  would  come  and  see  me  again  sometime 
next  week,  and  I  am  sending  you  this  letter  in  order  that  you  may 
bring  it  with  you  as  a  passport,  provided  you  are  the  one  who  was 
here  on  Wednesday. 

1  C.  W.  Beers.  A  Mind  that  Found  Itself.  1908.  New  York. 
Longmans,  Green  and  Co. 


178  MANUAL  OF  PSYCHIATRY. 

"  If  you  did  not  call  as  stated  please  say  nothing  about  this  letter 
to  anyone,  and  when  your  double  arrives,  I'll  tell  him  what  I  think 
of  him.  Would  send  other  messages,  but  while  things  seem  as  they 
do  at  present  it  is  impossible.  Have  had  some  one  else  address 
envelope  for  fear  letter  might  be  held  up  on  the  way. 

Yours, 

Cliffokd,  W.  B. 

"  Though  I  felt  reasonably  confident  that  this  me-ssage  would  reach 
my  brother,  1  was  by  no  means  certain.  I  was  sure,  however,  that, 
should  he  receive  it,  under  no  circumstances  would  he  turn  it  over 
to  any  one  hostile  to  myself.  When  I  wrote  the  words:  '  Dear 
George, '  my  feeling  was  much  like  that  of  a  child  who  sends  a  letter 
to  Santa  Glaus  after  his  faith  in  the  existence  of  Santa  Glaus  hiis  been 
shaken.  Like  the  sceptical  child,  I  felt  there  was  nothing  to  lose, 
but  everything  to  gain. 

"  The  thought  that  I  might  soon  get  in  touch  with  my  old  world 
did  not  excite  me.  I  had  not  much  faith  anyway  that  I  was  to 
re-establish  former  relations,  and  what  little  faith  I  had  was  almost 
dissipated  on  the  morning  of  August  30,  1902,  when  a  short  message, 
written  on  a  slip  of  i)aper,  reached  me  by  the  hand  of  an  attendant. 
It  informed  me  that  my  brother  would  call  that  afternoon.  I 
thought  it  a  lie.  I  felt  that  any  brother  of  mine  would  have  taken 
the  pains  to  send  a  letter  in  reply  to  the  first  I  had  written  him  in 
over  two  years.  The  thought  that  there  had  not  been  time  for  him 
to  do  so  and  that  this  message  must  have  arrivetl  by  telephone  did 
not  then  occur  to  me.  What  1  believed  was  that  my  own  letter  had 
been  confiscated.  I  asked  one  of  the  doctors  to  swear  on  his  honor 
that  it  really  was  my  own  brother  who  was  coming  to  see  me.  He 
did  so  swear,  and  this  may  have  diminished  my  first  doubt  some- 
what, but  not  much,  for  abnormal  suspicion  robbed  all  men  in  my 
sight  of  whatever  honor  they  may  have  had. 

"  The  thirtieth  of  the  month  was  what  might  be  called  a  perfect 
June  day  in  August.  In  the  afternoon,  as  usual,  the  patients  were 
taken  out  of  doors,  I  among  them.  I  wandered  about  the  lawn, 
and  cfist  frequent  and  exi)ectant  glances  toward  the  gate,  through 
which  1  believed  my  anticipated  visitor  would  soon  pass.  In  less 
than  an  hour  he  appeared.  I  first  caught  sight  of  liim  about  three 
hundred  feet  away,  and,  im|)elled  more  by  curiosity  than  hope,  I 
advanced  to  meet  him.  '  I  wonder  what  the  lie  will  be  this  time,' 
was  the  gist  of  my  thoughts. 


THE  PRACTICE  OF  PSYCHIATRY.  179 

"  The  person  approaching  me  was  indeed  the  counterpart  of  my 
brother  as  I  remembered  him.  Yet  he  was  no  more  my  bi  other 
than  he  had  been  at  any  time  during  the  preceding  two  years.  He 
was  still  a  detective.  Such  he  was  when  I  shook  his  hand.  As 
soon  as  that  ceremony  was  over  he  drew  forth  a  leather  pocket-book. 
I  instantly  recognized  it  as  one  I  myself  had  carried  for  several 
years  prior  to  the  time  I  was  taken  ill  in  1900.  It  was  from  this  that 
he  took  my  recent  letter. 

"  '  Here's  my  passport,'  said  he. 

"  '  It's  a  good  thing  you  brought  it, '  said  I  coolly,  as  I  glanced  at 
it  and  again  shook  his  hand  —  this  time  the  hand  of  my  own 
brother. 

"  '  Don't  you  want  to  read  it?'  he  asked. 

"  '  There  is  no  need  of  that, '  was  my  reply.    '  I  am  convinced.  .  .  •' 

"  This  was  the  culminating  moment  of  my  gradual  readjustment. 
...  In  a  word,  my  mind  had  foimd  itself." 

Of  the  methods  or  technique  of  psychotherapy  no 
full  discussion  can  be  given  here.  The  general  lines 
of  procedure  have  already  been  indicated.  For  an 
excellent  guide  in  practical  psychotherapy  the  reader 
is  referred  to  the  work  of  Dubois. 

PAROLE    AND    DISCHARGE.  AFTER-CARE. 

A  patient  who  presents  no  dangerous  or  trouble- 
some tendencies  and  who  has  improved  sufficiently 
to  justify  his  trying  to  live  outside  again  may  be, 
according  to  the  growing  custom  of  modern  insti- 
tutions, paroled  in  the  custody  of  relatives  or  friends 
for  a  period  which  varies  but  which  in  the  New  York 
state  hospital  service  may  be  as  long  as  six  months. 
If  during  the  parole  period  his  condition  requires 
a  return  to  the  hospital  no  legal  procedures  for  re- 
commitment are  necessary;  he  may  be  returned  by 
his  custodians  or  by  attendants  sent  by  the  hospital. 
If  he  gets  along  well  during  the  entire  period  of  his 


180  MANUAL  OF  PSYCHIATRY. 

parole   he   is   automatically   discharged   at   its   ex- 
piration. 

No  test,  no  method  of  examination  affords  a 
fairer  or  more  trustworthy  and  practical  means  of 
judging  a  patient's  ability  to  get  along  outside  of  an 
institution.  It  is  not  strange  therefore  that  the 
practice  of  paroling  patients  has  become  common  in 
all  institutions.  The  parole  statistics  of  the  Kings 
Park  State  Hospital,  at  Kings  Park,  New  York,  for 
the  year  ending  September  30,  1915,  may  be  cited 
as  an  example. 

On  parole  at  beginning  of  fiscal  year 324 

Paroled  during  the  year 507 

Average  number  on  parole 235 

Discharged  from  parole  during  the  year 456 

Returned  from  parole  during  the  year 174 

Remaining  on  parole  at  end  of  the  year 201 

Discharged  from  parole  and  recommitted 40 

The  parole  system  may  thus  be  seen  to  constitute 
an  important  extension  of  institutional  activity. 
This,  as  well  as  the  need  of  further  care  even  for  dis- 
charged patients,  renders  advisable  for  every  insti- 
tution or  system  of  institutions  the  organization  of 
a  bureau  or  department  for  systematic  after-care. 

When  a  patient  has  recovered  from  his  mental 
trouble  and  has  been  paroled  or  discharged  from  the 
hospital  the  treatment  of  his  case  must  not  be  re- 
garded as  finished,  for  there  is  still  to  be  dealt  with 
an  extreme  liability  to  recurrency. 

Of  a  total  of  6G89  cases  admitted  to  the  hospitals 
for  the  insane  in  the  State  of  New  York  during  the 
year  ending  September  30,  1908,  1388  were  cases  of 


THE  PRACTICE  OF  PSYCHIATRY.  181 

readmission.^  That  is  to  say,  that  minute  fraction 
of  the  population  which  consists  of  patients  dis- 
charged from  asylums  has  contributed  over  20%  of 
all  the  admissions. 

To  what  extent  is  recurrency  preventable? 

(1)  In  some  cases  recurrency  must  be  regarded  as 
probably  inevitable,  though  perhaps  it  can  be  staved 
off  by  general  hygienic  measures;  such  are  cases  of 
general  paresis  in  remission  and  well-established  cases 
of  manic  depressive  insanity. 

(2)  In  other  cases,  in  which,  in  addition  to  a  strong 
predisposition  to  mental  disturbance,  there  is  a 
history  of  some  removable  exciting  cause  in  the 
etiology  of  the  first  attack,  recurrency  may  often  be 
prevented  by  avoidance  of  re-exposure  to  the  original 
exciting  cause.  It  is  true  that  in  many  of  these 
cases  some  cause,  other  than  the  original  exciting 
cause,  may  give  rise  to  recurrency  owing  to  special 
vulnerability  of  the  parent's  mental  organization. 
Yet  it  cannot  be  doubted  that  in  a  good  proportion 
of  these  cases  prophylactic  measures  could  prove  very 
successful.  Among  the  common  avoidable  causes 
may  be  mentioned:  loss  of  employment,  overwork, 
inanition  and  exposure  due  to  poverty,  childbirth, 
and  neglected  somatic  diseases  (diabetes  in  which 
the  proper  diet  has  not  been  enforced,  nephritis  com- 
plicated through  neglect  of  treatment  by  ursemic 
delirium,  etc.). 

(3)  In  still  other  cases,  in  which  there  is  no  strong 
predisposition  and  in  which  the  trouble  is  due  en- 

1  Twentieth  Annual  Report  of  the  N.  Y.  State  Commission  in 
Lunacy. 


182  MANUAL  OF  PSYCHIATRY. 

tirely  to  some  avoidable  cause,  recurrency  can  he 
absolutely  'prevented.  This  is  a  large  group  of  cases 
consisting  of  the  alcohoUc  psychoses,  morphinism, 
cocainism,  etc. 

For  the  practical  and  efficient  after-care  of  the 
insane  with  a  view  to  the  prevention  of  recurrencies 
elaborate  facilities  are  required  which  could  be  es- 
tablished either  as  a  very  liberally  endowed  private 
chai'itable  organization  or,  and  perhaps  better,  by 
the  state,  as  an  After-care  Bureau. 

Such  an  organization  or  Bureau  should,  for  reasons 
that  are  sufficiently  obvious,  be  preferably  under 
the  directorship  of  a  physician  of  experience  in  the 
care  of  the  insane.  For  his  guidance  he  should 
have  on  file  a  transcript  of  the  hospital  records  of 
every  patient  that  is  discharged.  Connected  with 
the  Bureau  should  be  an  employment  agency,  a 
visiting  agency  —  for  the  purpose  of  visiting  dis- 
charged patients  at  their  homes  —  and  facilities  for 
the  temporar>^  housing  and  boarding  of  recovered 
patients  who  are  homeless  and  whom  it  may  be  par- 
ticularly important  to  keep  from  returning  to  their 
old  environment;  for  reasons  of  economy,  if  for  no 
others,  it  is  not  prudent  for  the  state  to  discharge 
from  its  care  '4nto  his  own  custody"  a  homeless 
bartender,  after  several  months  of  treatment  for 
alcoholic  hallucinosis:  his  only  friends  are  in  the 
saloon  where  he  was  employed,  or  in  some  other 
saloon,  and  there  is  hardly  anything  else  left  for 
hhn  to  do  than  to  go  back  to  them, — ^and  straight  to 
perdition,  —  to  have  recurrencies  and  ultimately  to 
become  a  permanent  charge  upon  the  state. 


CHAPTER  VIII. 

THE  PRACTICE   OF  PSYCHIATRY   {Concluded). 

PROGNOSIS.  — PREVALENCE  OF  MENTAL  DISORDERS: 
IS  INSANITY  ON  THE  INCREASE?  —  PREVENTION. 
—  MEDICO-LEGAL  QUESTIONS. 

Prognosis.  —  In  the  early  part  of  the  nineteenth 
centuiy,  when  the  care  of  the  insane  had  passed 
from  the  hands  of  the  clergy,  penal  authorities,  and 
poor-law  officials  to  those  of  physicians,  the  hope 
was  widely  entertained  that  the  medical  treatment 
which  thus  became  available  for  the  insane  would 
result  in  high  percentages  of  cures.  Thus,  in  one 
of  the  most  important  documents  in  the  history  of 
psychiatry'^  in  this  country,  a  report  under  date  of 
March  29,  1834,  made  to  the  New  York  state  legis- 
lature by  a  special  committee,  we  read:  ''It  is  now 
satisfactorily  established  that  diseases  of  the  mind 
yield  even  more  readily  to  medical  treatment  than 
those  of  the  body,  and  that  in  at  least  nine-tenths  of 
the  cases  of  insanity  the  patient  may  be  restored  to 
the  full  enjoyment  of  his  mental  faculties  by  the 
early  application  of  judicious  medical  treatment." 
To-day  not  the  most  sanguine  in  the  psychiatric 
branch  of  the  medical  profession  would  make  such 
an  assertion.  The  prognosis  of  insanity  is  more 
correctly  indicated  by  the  following  analysis  of  the 
recovery  statistics  of  the  Kings  Park  State  Hospital, 
at  Kings  Park,  New  York,  for  the  year  ending  Sep- 
tember 30,  1915. 

183 


184  MANUAL  OF  PSYCHIATRY. 

214  cases  were  discharged  during  the  year  as  ' 're- 
covered," making  the  recovery  rate,  based  on  direct 
admissions,  20.78%.  Many  of  these  reported  re- 
coveries, however,  can  be  regarded  as  such  only  from 
a  non-medical  point  of  view;  for  of  these  cases  31 
were  suffering  at  the  time  of  their  discharge  from 
epilepsy,  imbecility,  constitutional  inferiority,  or 
paralysis  agitans,  having  recovered  merely  from  their 
''insanity,"  i.e.,  from  acute  psychotic  manifestations 
which  had  led  to  their  commitment;  49  had  had 
one  or  more  previous  admissions  to  institutions 
for  the  insane  and  were  evidently  recurrent  cases 
without  any  likelihood  of  continued  mental  health 
in  the  future;  13  had  recovered  from  alcoholic 
psychoses  but  probably  not  from  the  habit  of  in- 
temperance; and  24  had  been  classed  as  constitu- 
tionally of  inferior  or  defective  make-up  and  had 
recovered  not,  of  course,  from  their  inferiority  or 
defectiveness  but,  like  the  first  mentioned  group, 
merely  from  acute  psychotic  manifestations  which 
had  led  to  their  commitment. 

This  leaves  but  97  cases  which  can  be  said  to  have 
recovered  in  the  sense  of  having  shown  at  the  time 
of  their  discharge  a  real  freedom  from  demonstrated 
psychic  abnonnality.  But  if  the  universal  past 
experience  is  a  trustworthy  guide,  then  it  is  un- 
fortunately but  too  sure  that  a  certain  proportion 
even  of  this  remnant  will  prove  sooner  or  later  to  be 
of  a  recurrent  natui'o;  so  that  it  is  extroniely  doubt- 
ful if  complete  and  ])onnanent  recoveries  have  oc- 
curred in  more  than  5%  of  all  cases  admitted. 

It  should  be  added  here  that  the  experience  of  the 


THE  PRACTICE  OF  PSYCHIATRY.  185 

Kings  Park  State  Hospital  is,  in  this  respect,  by  no 
means  unique;  on  the  contrary,  it  is  but  the  general 
experience  of  psychiatric  practice  all  over  the  world, 
as  may  be  judged  from  the  following  passage  quoted 
from  Kraepelin:  ^  ''Only  a  comparatively  small  per- 
centage of  cases  are  permanently  and  completely 
cured  in  the  strictest  sense  of  the  word."  This 
statement,  we  believe,  voices  the  concensus  of  com- 
petent psychiatric  opinion. 

It  would  seem  from  this  that  radical  dealing  with 
the  problems  of  mental  disease  must  be  by  way  of 
prevention  and  not  treatment. 

Prevalence  of  Mental  Disorders:  Is  Insanity  on 
the  Increase?  ^  —  During  the  past  several  decades  the 
number  of  insane  in  institutions  has  been  increasing 
at  a  faster  rate  than  the  general  population.  Thus, 
according  to  the  United  States  census  statistics  there 
were,  in  1880,  81.6  patients  in  institutions  for  the 
insane  per  hundred  thousand  of  the  general  popu- 
lation; in  1910  the  number  had  risen  to  204.2.  To 
what  extent,  if  any,  does  this  fact  indicate  an  actual 
increase  in  the  prevalence  of  insanity  in  the  Amer- 
ican population? 

There  can  be  no  doubt  that,  at  least  to  some  ex- 
tent, the  increase  of  patients  in  institutions  is  due 
merely  to  the  general  improvement  in  the  kind  and 
adequacy  of  facilities  for  their  care;  and  if  the 
statistics  of  various  states  for  any  one  year  are  com- 

1  Kraepelin.  Lectures  on  Clinical  Psychkilry.  Second  edition 
in  English,  New  York,  1906.     P.  2. 

2  A.  J.  Rosanoff.  7s  Insanity  on  the  Increase?  Journ.  Amer. 
Med.  Ass'n.,  July  24,  1915. 


186  MANUAL  OF  PSYCHIATRY.      " 

pared  with  one  another,  marked  differences  are  found, 
corresponding  to  stages  of  progress  in  social  organiza- 
tion, and  altogether  analogous  to  those  shown  by 
the  entire  country  in  years  separated  by  decades. 

Thus,  for  instance,  in  1910  there  were  in  the  state 
of  Oklahoma  67  patients  in  institutions  per  hundred 
thousand  of  the  general  population,  while  in  the 
state  of  Massachusetts  there  were  344.6 ;  and  between 
these  extremes  all  degrees  of  transition  were  pre- 
sented by  the  statistics  of  other  states. 

It  is  obvious,  therefore,  that  the  number  of  patients 
in  institutions,  either  in  the  entire  country  at  differ- 
ent times  or  in  different  parts  of  it  at  any  one  time, 
cannot  be  taken  as  a  correct  measure  of  the  prev- 
alence of  insanity  among  the  people. 

For  this  reason,  attempts  have  been  repeatedly 
made  to  enumerate  the  total  number  of  insane  per- 
sons both  in  and  out  of  institutions  in  the  various 
states.^  The  resulting  data  were,  however,  so  mani- 
festly untrustworthy  that  eventually  it  became 
apparent  that  the  difficulties  inherent  in  such  an 
undertaking  were  greater  than,  for  the  present,  we 
can  cope  with  successfully,  and  such  attempts  have, 
accordingly,  been  given  up. 

Of  these  difficulties  the  greatest  and,  perhaps,  the 
sole  insumiountable  one  is  that  of  fonnulating  such 
a  definition  of  insanity  as  to  enable  enumerators 
readily  and  uniformly  to  distinguish  between  sane 
and  insane  persons,  under  all  conditions. 

Furtluirmore,  whoever  is  familiar  with  psychiatric 


1  U.  H.  ('('tiHUrf  from  1850  to  1890. 


THE  PRACTICE  OF  PSYCHIATRY.  187 

clinical  material  knows  that,  owing  to  the  nature  of 
tilings,  even  if  it  were  possible  to  formulate  a  defini- 
tion and  thereby  draw  a  line  sharply  distinguishing, 
for  practical  purposes,  sanity  from  insanity,  the  hne 
could  be  thus  drawn  only  in  relation  to  some  more 
or  less  arbitrary  standard  of  normality. 

The  need  of  standards  of  normality  is  felt  not  only 
in  connection  with  attempts  of  enumeration  of  the 
insane  in  communities,  but  also  in  daily  practice  in 
connection  with  every  case  of  alleged  insanity  in 
which  commitment  to  an  institution  is  sought;  and 
in  this  respect  the  practice  of  the  various  states, 
varying  as  it  does  within  wide  limits,  indicates  the 
application  of  a  whole  series  of  fairly  distinct, 
though  not  readily  definable,  standards. 

Thus,  referring  again  to  the  instances  presented  by 
Oklahoma  and  Massachusetts,  significance  attaches 
mainly  to  the  consideration  that  there  are  undoubt- 
edly many  persons  residing  in  the  former  state  who 
are  at  large  and  whom,  moreover,  their  fellow  citi- 
zens do  not  consider  proper  subjects  for  an  insane 
hospital,  who  would  be  promptly  committed  if  they 
took  up  their  residence  in  the  latter  state.  In  the 
last  analysis,  it  is  a  difference  in  tacitly  accepted 
standards  of  normality  that  accounts  largely  for  the 
fact  that  in  Oklahoma,  as  already  stated,  there  were 
but  67  patients  in  institutions  per  hundred  thousand 
of  the  general  population,  while  in  Massachusetts 
there  were  no  less  than  344.6;  and  similar  differences 
in  standards  no  doubt  account  for  the  analogous 
contrasts  presented  by  statistics  of  the  insane  in 
institutions  in  the  entire  countiy  at  different  times. 


188  MANUAL  OF  PSYCHIATRY. 

Persons  are  placed  in  institutions  when,  by  reason 
of  some  mental  defect  or  disturbance,  their  adapta- 
tion to  their  environment  fails.  The  environment  of 
a  highly  organized  community  with  high  standards 
of  hving  is,  of  course,  more  exacting  than  that  of 
a  community  characterized  by  a  more  primitive 
organization  and  lower  standards. 

Whatever  may  be  one's  theoretical  conception  of 
insanity,  the  line  of  division  between  it  and  the 
normal  condition,  as  it  is  indicated  by  the  practice 
of  communities,  is  a  shifting  one,  moving  from  the 
abnonnal  toward  the  normal  extreme  with  the  prog- 
ress of  civilization  and  the  concomitant  elevation  of 
social  standards. 

These  considerations  are  of  importance,  as  they 
point  a  way  to  an  indirect  method  of  investigating 
the  question  which  is  before  us,  Is  insanity  on  the 
increase?  For,  although  it  would  be,  of  course,  im- 
possible to  apply  a  newly-selected  standard  to  con- 
ditions in  the  remote  past  concerning  which  we  have 
no  information  other  than  that  recorded  by  contem- 
porary observers,  it  is  at  least  within  the  bounds  of 
possibility  to  apply  such  a  standard  in  studying 
conditions  in  various  parts  of  the  countr}'^  as  they 
exist  in  our  own  time. 

The  states  east  of  the  Mississippi  River  may  be 
divided  into  a  Northern  group,  comprising  Con- 
necticut, Illinois,  Indiana,  Maine,  Massachusetts, 
Michigan,  New  Hampshire,  New  Jersey,  New  York, 
Ohio,  Pennsylvania,  Rhode  Island,  Vennont,  and 
Wisconsin;  and  a  Southern  group,  comprising  Ala- 
bama, Delaware,  Florida,  Georgia,  Kentucky,  ]\Iary- 


THE   PRACTICE  OF  PSYCHIATRY.  189 

land,  Mississippi,  North  Carolina,  South  Carolina, 
Tennessee,  Virginia,  and  West  Virginia. 

Facilities  for  the  care  of  the  insane  have  at  all 
times  been  relatively  more  ample  in  the  Northern 
group  of  states,  and,  accordingly,  the  number  of 
patients  in  institutions  in  relation  to  the  general 
population  has  always  been  greater,  as  shown  in  the 
accompanying  table. 

Number  of  Insane  in  Institutions  per  Hundred  Thousand  of 
THE  General  Population  in  Certain  Years  in  Two  Groups 
OF  States  East  of  the  Mississippi  River. 

/ Census  Years % 

1880  1890  1904  1910 

Northern  group 104.9        145.1        230.7        256.6 

Southern  group 48.8  79.7        117.5        132.3 

The  difference  between  these  two  groups  of  states 
is  certainly  very  striking.  From  what  has  been  said 
it  would  follow  that  the  question,  To  what  extent 
does  this  difference  correspond  with  a  real  difference 
in  incidence  of  insanity?  is  lacking  in  definiteness. 
It  may  be  better  expressed  as  follows:  If  the  popu- 
lations of  the  two  groups  of  states,  or  representative 
portions  of  them,  were  exposed  to  the  same  environ- 
mental conditions,  would  there  still  be  a  difference 
between  them  as  to  the  proportion  of  patients  con- 
tributed to  insane  hospitals;  and,  if  so,  which  group 
would  contribute  the  higher  proportion  and  how 
great  would  be  the  difference? 

One  advantage  in  thus  expressing  the  question  is 
that  it  affords  a  suggestion  of  a  method  for  seeking 
an  answer. 


190  MANUAL  OF  PSYCHIATRY. 

A  number  of  circumstances,  such  as  availability 
of  good  statistics,  the  prevalence  of  high  social 
standards,  the  composition  of  the  population  which 
is  in  certain  respects  peculiar,  etc.,  combine  to  make 
the  experience  of  the  state  of  California  worthy  of 
special  study  in  this  connection. 

The  growth  of  the  population  of  that  state  has  for 
a  number  of  decades  been  in  large  part  by  immigra- 
tion from  other  states,  especially  those  east  of  the 
Mississippi  River.  This  fact  has  created  an  oppor- 
tunity of  making  a  comparison  such  as  we  desire 
to  make,  in  order  to  find  an  answer  to  the  question 
that  is  before  us,  by  noting  the  number  of  admissions 
to  the  state  hospitals  of  California  contributed  by 
natives  of  the  above-mentioned  two  groups  of  states 
who  have  taken  up  their  residence  in  California. 

If  the  incidence  of  insanity  differs  materially  in 
these  two  groups  of  states,  it  would  seem  that  the 
difference  should  be  revealed  by  this  comparison  — 
one  that  is  made  on  the  basis  of  a  standard  which, 
though  not  to  be  theoretically  formulated,  is  never- 
theless fairly  definite,  uniform  and  readily  applicable, 
namely,  the  standard  of  the  prevailing  environmental 
conditions  of  California. 

During  the  biennial  period  ending  June  30,  1910,^ 
the  natives  of  the  Northern  group  of  states  residing 
in  California  furnished  147.3  admissions  to  the  state 
hospitals  of  California  per  hundred  thousand  of  their 
general  population.  During  the  same  period  the 
natives  of  the  Southern  group  of  states  furnished 

*  Seventh  Biennial  Report  of  the  State  Commis«ion  in  Lunacy  of 
California. 


THE  PRACTICE  OF  PSYCHIATRY.  191 

166.7  admissions  per  hundred  thousand:  a  differ- 
ence of  13.1%. 

In  other  words,  as  far  as  may  be  judged  from  these 
statistics,  the  Southern  states  east  of  the  Mississippi 
River,  which  have  had  for  many  years,  and  still  have, 
poorer  and  less  adequate  facilities  for  the  care  of 
their  insane  than  the  Northern,  now  show  a  higher 
incidence  of  insanity  in  their  population. 

Thus  it  would  seem  that  the  much  greater  relative 
number  of  insane  in  institutions  in  the  Northern 
group  of  states  is  but  an  indication  of  a  more  thor- 
oughly carried  out  policy  of  segregation,  and  appears 
to  have  already  produced  a  demonstrable  eugenic 
effect:  for  the  application  of  a  common  standard  to 
representative  portions  of  the  two  population  groups 
reveals  evidence  showing  that  the  incidence  of  in- 
sanity is  actually  greater  in  the  Southern  group. 

Similarly,  it  would  appear  that  the  progressive 
increase  in  the  relative  number  of  institution  in- 
mates, observed  throughout  the  country  during  the 
past  several  decades,  is  also  but  an  indication  of 
more  thorough  segregation  which  has,  in  all  prob- 
ability, been  attended  by  the  same  eugenic  effect. 

The  conclusion  seems  justifiable,  then,  that  such 
evidence  as  is  available,  far  from  showing  that  in- 
sanity is  on  the  increase,  tends  to  show  rather  that 
it  is  on  the  decline. 

Prevention.^  —  As  stated  in  the  chapter  on  eti- 
ology, amongst  the  many  causes  of  mental  disease 
may  be  distinguished  some  few  that  are  essential 

^  A.  J.  Rosanoff.  Causes  and  Prevention  oj  Insanity.  The  Long 
Island  Med.  Journ.,  Sept.,  1915. 


192  MANUAL  OF  PSYCHIATRY. 

from  others  that  are  merely  incidental  or  contribut- 
ing. 

There  are  few  persons,  if  indeed  there  are  any,  who 
are  so  fortunate  as  to  go  through  life  without  being 
repeatedly  subjected  to  the  influence  of  some  of  the 
incidental  causes:  the  prevention  of  insanity  will 
consist  largely  in  measures  for  combating  the  essen- 
tial causes,  —  heredity,  alcohoUsm,  syphilis,  and 
head  injuries. 

Measures  for  the  prevention  of  insanity  may  be 
undertaken  by  the  individual  or  by  society.  As  far 
as  the  average  healthy  individual  is  concerned  the 
measures  are  few  and  simple;  it  must,  however,  be 
noted  as  a  fact  which  has  been  repeatedly  demon- 
strated under  the  most  varied  conditions,  that  the 
great  mass  of  individuals,  even  if  made  fully  aware 
of  all  dangers,  will  not  practice  preventive  measures 
in  any  systematic  manner;  this  is  perhaps  due  to  a 
curious  trait  of  human  nature  owing  to  which  men 
are  disinclined  to  believe  that  any  evil  may  befall 
them  and  therefore  have  a  tendency  to  take  chances; 
further  it  must  be  remembered  that  the  great  causes 
of  insanity  appear  in  the  shape  of  strong  tempta- 
tions which  are  difficult  and  for  some  impossible  to 
resist.  However  this  may  be,  those  who  are  con- 
cerned with  the  problem  of  the  prevention  of  in- 
sanity would  be  impractical  if  they  relied  entirely 
upon  dissemination  of  knowledge  on  this  subject 
among  the  people  with  the  hope  of  thus  reducing  to 
a  material  extent  the  incidence  of  insanity.  Dissem- 
ination of  knowledge  should,  I  believe,  be  regarded 
as  a  preliminary  step  which  will  make  possible  the 


THE  PRACTICE  OF  PSYCHIATRY.  193 

application  of  large  measures  by  society  as  a  whole, 
—  and  nothing  short  of  that  will  constitute  an 
effective  system  of  mental  hygiene. 

The  prevention  of  bad  heredity  affords  a  hope  of 
reducing  not  only  the  constitutional  mental  disorders, 
but  also  those  which  develop  on  the  basis  of  alcohol- 
ism and  of  syphilis,  as  may  be  judged  from  the  fol- 
lowing considerations. 

As  regards  alcoholic  psychoses,  it  is  not  sufficient 
to  know  that  they  result  from  intemperance.  In 
order  to  be  able  to  deal  properly  with  the  problem 
of  prevention  an  answer  must  be  sought  to  the  ques- 
tion. Why  do  some  persons  drink  alcohol  in  injuri- 
ous quantities?  —  The  general  view  is  that  initiation 
into  habits  of  intemperance  occurs  as  a  result  of 
convivial  customs  or  through  bad  associations,  and 
that  in  such  ways  a  craving  is  established  which 
leads  to  the  development  of  chronic  alcoholism. 
This  is  the  truth,  but  not  the  whole  truth;  for  in 
the  midst  of  the  same  social  conditions,  favorable  or 
unfavorable,  it  is  as  certain  that  some  persons  will 
become  alcohoUc  as  it  is  that  others  will  not.  The 
difference  is  between  the  persons. 

During  the  fiscal  year  ending  September  30,  1914, 
56  cases  of  alcoholic  psychoses  were  admitted  to  the 
Kings  Park  State  Hospital;  in  18  of  these  data  con- 
cerning heredity  and  mental  make-up  of  the  patients 
were  unascertained;  of  the  remaining  38  cases  no 
less  than  31  presented  either  a  neuropathic  family 
history,  or  an  originally  inferior  mental  make-up, 
or  both;  and  only  7  gave  a  negative  personal  and 
family  history. 


194  MANUAL  OF  PSYCHIATRY. 

The  conditions  under  which  such  hospital  statistics 
are  compiled  as  a  rule  give  rise  to  error  in  but  one 
direction,  namely,  in  the  direction  of  omitting  perti- 
nent facts  of  family  or  personal  history;  thus  tend- 
ing to  lead  to  an  underestimation  of  the  case  from 
this  point  of  view.  Considering  this,  the  remark- 
able showing  of  the  figures  must  give  one  the  feeling 
that  the  tendency  to  drink  alcohol  in  amounts  suffi- 
cient to  produce  insanity  is  largely  a  neuropathic 
manifestation. 

A  study  of  this  subject,  made  by  Dr.  D.  Heron  ^ 
and  published  recently  from  the  Galton  Labora- 
tory of  Eugenics  at  the  University  of  London,  has 
yielded  a  similar  conclusion:  ''We  are  on  fairly 
safe  ground  in  asserting  that  the  relationship  be- 
tween inebriety  and  mental  defect  is  about  0.76. 
We  have  thus  reached  a  definite  measure  of  a  rela- 
tionship on  which  every  authority  on  alcoholism  has 
laid  the  greatest  possible  stress."  ''On  the  one 
hand,  mental  condition  is  usually  regarded  as  being 
directly  affected  by  alcoholic  excess,  and  on  the 
other  hand  the  extent  of  the  individual's  education 
is  very  largely  determined  by  causes  which  are  pre- 
alcoholic;  yet  we  find  here  that  there  is  a  close 
relationship  between  the  two  characters,  and  this 
is  strongly  in  favor  of  the  view  that  the  defective 
mental  condition  of  these  inebriates,  like  the  extent 
of  their  education,  is  pre-alcoholic  and  that  the  alco- 
holism flows  from  a  pre-existing  mental  defect,  not 
the  mental  defect  from  the  alcoholism."     "All  this 

1  Eugpuics  Laboratory  Menioira,  xvii:  A  Second  Study  of  Extreme 
Alcoholism  in  Adidts.     London,  1912. 


THE  PRACTICE  OF  PSYCHIATRY,  195 

lends  support  to  the  view  that  the  mental  defect  of 
the  inebriate  is  not  an  actual  growth;  it  is  born,  not 
bred;  that  'inebriety  is  more  an  incident  in  the  life 
of  the  inebriate  than  the  cause  of  his  mental  defect. ' " 

As  regards  syphilis  in  this  connection,  it  is  neces- 
sary to  consider  before  all  the  manner  in  which  it  is 
spread  so  widely  through  the  population. 

Syphilitic  infection,  as  is  well  known,  may  be  of 
non-venereal  as  well  as  of  venereal  origin.  Thus,  of 
887  cases  reported  by  Fournier,^  45  were  of  non- 
venereal  origin,  among  these  being  cases  of  in- 
herited syphilis,  of  infection  of  wet-nurses  by  suck- 
lings, mid  wives  by  women  in  labor,  etc.  Of  the 
cases  of  venereal  origin,  not  all  result  from  immoral 
relations.  Thus  Fournier  ^  estimates  that  of  all 
cases  in  women  the  infection  in  19%  is  acquired  by 
married  women  from  their  husbands.  But  even  in 
cases  in  which  the  infection  is  acquired  innocently, 
it  can  usually  be  traced  indirectly  to  immoral  sex- 
ual relations,  particularly  to  prostitution,  as  its 
original  source. 

The  prevention  of  syphilis  and  with  it  of  psychoses 
of  syphilitic  origin  is,  therefore,  closely  linked  to  the 
prevention  or  control  of  prostitution. 

To  what  extent  can  prostitution  be  controlled? 

First  of  all,  it  must  be  noted  that  at  no  time  has 
any  state  or  nation  as  yet  succeeded  in  abolishing 
prostitution,  and  as  late  as  1902  a  Committee  of 
Fifteen,  organized  in  New  York  for  the  purpose  of 

^  Fournier.     The  Treatment  and  Prophylaxis  of  Syphilis.     Eng- 
lish translation  by  C.  F.  Marshall.     New  York,  1907.     P.  348. 
2  Loc.  cit.,  p.  351. 


196  MANUAL  OF  PSYCHIATRY. 

investigating  the  social  evil,  were  led  in  their 
report  to  express  the  view  that  the  summary  ex- 
tirpation of  prostitution  "in  the  present  state  of  the 
moral  evolution  of  the  race,  is  as  yet  impossible. "  ^ 

Since  that  time,  however,  important  additions 
have  been  made  to  our  knowledge  of  prostitution, 
so  that  to-day  the  case  no  longer  seems  so  hopeless. 
The  most  significant  contribution  consists  in  the 
discovery  of  the  close  relationship  existing  between 
prostitution  and  feeble-mindedness  and  other  mental 
disorders. 

This  relationship  has  been  carefully  studied  by  a 
special  commission  created  for  that  purpose  by  an 
act  of  the  House  of  Representatives  of  the  State 
of  Massachusetts. 2  We  would  quote  the  following 
from  their  highly  interesting  official  report:  "The 
women  examined  were  in  three  groups:  young  girls 
under  sentence  in  the  State  Industrial  School  for 
Girls,  the  House  of  Refuge,  and  the  Welcome  House; 
those  just  arrested  and  awaiting  trial  in  the  Suffolk 
House  of  Detention  in  Boston;  women  serving  sen- 
tence in  the  State  Reformatory  for  Women,  the 
Suffolk  County  Jail,  and  the  Suffolk  House  of  Cor- 
rection. 

"These  three  groups  represent  the  young  girls 
who  have  just  begun  prostitution,  the  women  plying 
their  trade  on  the  streets  at  the  present  time  and  the 


>  The  Social  Evil.  New  York,  1902.  (G.  P.  Putnam's  Sons) 
p.  17S. 

^  Report  of  the  Commission  for  the  Investigation  of  the  White 
Slave  Traffic,  sf>-called.  February,  1914.  House,  No.  2281,  State 
of  Massachusetts. 


THE  PRACTICE  OF  PSYCHIATRY.  197 

women  who  are  old  offenders.  The  houses  of 
prostitution,  lodging  houses,  hotels  and  cafes  named 
by  these  women  as  the  places  where  they  plied  their 
trade  are  the  same  as  those  noted  by  the  field  in- 
vestigators employed  by  the  commission. 

"The  Binet  tests  were  applied  to  289  of  the  300 
women  examined,  and  other  psychological  tests  were 
used  in  doubtful  cases. 

"Of  the  300  prostitutes,  154,  or  51%,  were  feeble- 
minded and  11,  or  3%,  were  insane.  All  doubtful 
cases  were  recorded  as  normal.  The  mental  defect 
of  these  154  women  was  so  pronounced  and  evident 
as  to  warrant  the  legal  commitment  of  each  one  as 
a  feeble-minded  person  or  as  a  defective  delinquent. 
At  the  Massachusetts  School  for  the  Feeble-minded 
there  are  an  equal  number  of  women  and  girl  in- 
mates, medically  and  legally  certified  as  feeble- 
minded, who  are  of  equal  or  superior  mental  capacity. 

"The  135  women  designated  as  normal  as  a  class 
were  of  distinctly  inferior  intelligence.  More  time 
for  study  of  these  women,  more  complete  histories 
of  their  life  in  the  community  and  opportunity  for 
more  elaborate  psychological  tests  might  verify  the 
belief  that  many  of  them  also  were  feeble-minded  or 
insane. 

"Some  of  the  women  seen  at  the  Detention  House 
were  so  under  the  influence  of  drugs  or  alcohol  as  to 
make  it  impossible  to  study  their  mental  condition. 
Others  at  the  Detention  House  and  in  the  prisons 
had  used  alcohol  to  excess  for  years,  and  in  the  time 
available  it  was  impossible  to  differentiate  between 
alcoholic   deterioration   and  mental   defect.     These 


198  MANUAL  OF  PSYCHIATRY. 

drunken,  alcoholic  and  drug-stupefied  women  were 
all  recorded  as  normal. 

"Of  the  135  women  rated  as  normal,  only  a  few 
ever  read  a  newspaper  or  a  book,  or  had  any  real 
knowledge  of  current  events,  or  could  converse 
intelligently  upon  any  but  the  most  trivial  subjects. 
Not  more  than  six  of  the  entire  number  seemed  to 
have  really  good  minds. 

"  It  has  long  been  held  that  prostitution  always  has 
existed  and  always  will  exist,  and  that  all  remedies 
will  be  ineffective  and  of  no  avail,  because  it  repre- 
sents a  variation  of  the  most  fundamental  human 
instinct. 

"Recent  studies  of  prostitution  and  prostitutes  in 
other  cities,  states,  and  countries,  and,  in  connection 
with  this  investigation,  the  study  and  analysis  of  300 
prostitutes  individually  examined  for  the  commission, 
the  observation  of  prostitutes  and  prostitution,  and 
of  the  immoral  young  girls  who  have  not  entered 
prostitution  in  cities  and  towns  all  over  the  State, 
have  convinced  the  commission  that  this  evil  is 
susceptible  of  successful  attack  and  treatment.  The 
fact  that  one-half  of  the  women  examined  were 
actually  feeble-minded  clears  the  way  for  successful 
treatment  for  this  portion  of  this  class.  The  mental 
status  of  the  })rostitutes  under  arrest  should  be  de- 
termined, and  such  of  them  as  are  found  to  be  feeble- 
minded or  defective  delinquents  should  be  placed 
under  custodial  treatment.  Thus  would  these  women 
themselves  be  saved  from  an  evil  fate,  pimps  and 
procurers  would  lose  their  willing  prey,  and  a  non- 
self-sui){)orting  class  who  find  in  prostitution  their 


THE  PRACTICE  OF  PSYCHIATRY.  199 

only  way  of  earning  a  living  would  be  taken  out  of 
the  community. 

"The  recognition  of  feeble-minded  girls  at  an 
early  age  in  the  public  schools,  and  proper  provision 
for  their  protection  in  the  community  or  custodial 
care  in  an  institution,  would  prevent  much  of  the 
observed  immorality  among  young  girls  and  the 
resulting  temptations  to  boys.  Precocious  sex  in- 
terests and  practices  are  well-known  symptoms  of 
feeble-mindedness. " 

The  situation,  then,  may  be  sunamarized  as  fol- 
lows: at  least  three-fourths  of  all  cases  of  insanity 
occur  on  the  basis  of  bad  heredity,  alcoholism,  or 
syphilis;  an  individual  who  is  of  normal  ancestry, 
abstains  from  alcohol  and  remains  free  from  syphilitic 
infection  is  not  seriously  threatened  with  mental 
alienation.  But  since  alcoholism  and  syphilis  are, 
in  their  turn,  so  generally  connected  either  directly 
or  indirectly  with  inherent  mental  defectiveness,  it 
follows  that  heredity  is,  as  long  taught  with  charac- 
teristic clearness  of  thought  and  diction  by  the 
French  school  of  psychiatry,  the  cause  of  causes  of 
mental  alienation. 

It  may  safely  be  said,  therefore,  that  a  movement 
for  the  prevention  of  mental  disorders  will  lead  the  race 
in  no  mistaken  path  if  it  concentrates  the  hulk  of  its 
energies  on  the  problem  of  had  heredity. 

The  means  that  have  been  suggested  for  combating 
bad  heredity  are  legal  restriction  of  marriage,  surgical 
sterilization,  and  segregation.  This  would,  perhaps, 
hardly  be  the  place  for  a  full  discussion  of  the  ad- 
vantages and  disadvantages  of  all  these  measures; 


200  MANUAL  OF  PSYCHIATRY. 

nor  is  it  to  be  assumed  that  any  one  of  them  is  to  be 
adopted  necessarily  to  the  complete  exclusion  of  the 
others.  Suffice  it  to  say  here  that  the  main  draw- 
back of  marriage  laws  in  this  connection  is  their 
ineffectiveness;  and  that  to  sterilization  there  are 
moral,  religious,  legal,  and  even  scientific  objections 
which  render  it  largely  unacceptable  to  public  opin- 
ion. On  the  other  hand,  segregation,  though  also 
op])osed  by  some,  is  evidently  much  more  generally 
acceptable,  as  is  shown  by  the  fact  that,  quite  inde- 
pendently of  any  consciously  eugenic  movement,  its 
practice  has  made  great  headway  during  the  past 
several  decades. 

We  may  conclude,  therefore,  that,  unlike  other 
eugenic  measures  that  have  been  proposed,  segre- 
gation is  an  old  practice  which  has  been  tried  out 
everywhere  and  to  which  no  effective  objections 
have  been  raised  either  on  religious,  or  legal,  or 
humanitarian  grounds;  it  has  had  of  late  a  remark- 
able growth;  and  it  may  be  anticipated  that  with 
the  growth  of  urban  centers,  progress  in  popular 
education,  improvement  of  methods  of  financing,  and 
the  rise  in  standards  of  uistitution  care  will  come 
vast  possibihties  of  further  growth.^ 

If  insanity  is  to  so  large  an  extent  a  heritage  from 
past  generations,  resulting  from  untold  centuries  of 
neglect  of  segregation;  and  if  the  very  incomplete 
segregation  that  has  been  practiced  in  but  two  or 

'  A.  J.  Rosanoff.  A  Shidij  of  Eugenic  Forces.  Particularly  of 
Social  Co7iditio7is  which  Bring  About  the  Segregation  of  Neuropathic 
Persons  in  Special  Institutio7is.  Amcr.  Journ.  of  Insanity,  Oct., 
1915. 


THE  PRACTICE  OF  PSYCHIATRY.  201 

three  generations  can  already  be  shown  to  have 
made  an  impression  on  this  ancient  problem  (see 
p.  191);  then  it  would  seem  that  we  have  at  last 
arrived  at  a  point  where  we  need  to  consider  but 
ways  and  means;  for  we  are  in  a  position  to  say 
to  the  people  and  to  legislatures,  Mental  health  is 
purchasable;  the  prevalence  of  mental  disorders  can  be 
reduced  for  coming  generations  with  the  aid  of  dollars 
and  cents  spent  for  segregation  in  this  generation. 

Direct  efforts  for  the  prevention  of  alcoholism  and 
of  syphilis,  independently  of  the  measures  for  com- 
bating bad  heredity,  are  by  no  means  to  be  neg- 
lected. 

Abstinence.  —  The  most  trustworthy  experimen- 
tal data  seem  to  show  that  even  moderate  indulgence 
in  alcohol,  though  producing  in  the  subject  a  sense 
of  well-being  and  of  increased  physical  and  mental 
abiUty,  in  reaUty  causes  impairment  of  muscular 
power  and  coordination  and  of  mental  efficiency.^  In 
persons  of  neurotic  constitution  comparatively  slight 
indulgence  often  causes  severe  mental  disturbance. 

Those  who  favor  temperance  rather  than  absti- 
nence do  so  mainly  on  the  basis  of  the  usefulness  of 


^  L.  Schneider.  Alkuhol  und  Muskelkrajt.  Pfliigers  Arch.  f.  d. 
ges.  Physiol.,  Vol.  93,  p.  451.  —  M.  Mayer.  JJeher  die  Beein- 
flussung  der  Schrift  durch  den  Alkohol.  Kraepelins  Psychol.  Arb., 
Vol.  Ill,  p.  535.  —  G.  Aschaffenburg.  Prcktische  Arbeit  unter  Alko- 
holwirkung.  Kraepelins  Psychol.  Arb.,  Vol.  I,  p.  608.  —  A.  Smith, 
Ueber  die  Beeinjlussung  einfacher  psychischer  Vorgdnge  durch  chron- 
ische  Alkoholvergiftung.  Br.  iib.  d.  V.  intern.  Kongr.  z.  Bekampf. 
d.  Missbr.  geist.  Getranke.  Basel,  1896,  p.  341.  —  E.  Kiirz  and 
E.  Kraepelin.  Ueber  die  Beeinjlussung  'psychischer  Vorgdnge  durch 
regelmdssigen  Alkoholismus.  Kraepelins  Psychol.  Arb.,  Vol.  Ill, 
p.  417. 


202  MANUAL  OF  PSYCHIATRY. 

alcohol  as  a  food  and  as  a  sedative  contributing  to 
the  recuperative  effect  of  rest  by  promoting  complete 
relaxation.  It  is  not  to  be  disputed  that  alcohol 
does  possess  these  beneficial  qualities,  but  it  is  not 
possible  to  derive  the  benefit  and  yet  escape  the  harm 
from  using  it.  Moreover  moderate  indulgence,  if 
regular,  leads  but  too  often  to  the  development  of 
uncontrollable  craving,  increase  of  dosage,  and  ulti- 
mately to  chronic  alcoholism.  It  need  hardly  be 
added  that  alcohol  either  as  a  food  or  as  a  sedative 
is  not  a  physiological  necessity. 

Therefore  the  advice  to  the  individual  must  usually 
be:   complete  abstinence  without  compromise. 

Of  measures  that  may  be  employed  by  society  the 
most  important  is  dissemination  of  the  knowledge  of  the 
true  effect  of  alcohol,  which  should  constitute  a  part 
of  the  program  of  all  public  schools.  It  is  necessary 
before  all  to  dispel  the  prevailing  notions  that  alcohol 
is  harmful  only  when  taken  in  excess  and  that,  taken 
in  moderation,  it  is  beneficial  and  even  necessary  to 
the  laborer  or  artisan. 

The  next  in  importance  are  legislative  measures. 
As  having  been  actually  proved  to  be  in  some  degree 
effective  may  l)e  mentioned:  (1)  The  Gothenburg 
system,  (2)  prohibition,  and  (3)  local  option. 

The  Gothenburg  systejn  was  first  instituted  in 
Sweden,  and  has  since  been  adopted  by  Norway  and 
Finland.  The  Swedish  Law  of  1855  gives  to  each 
municipality  the  right  of  prohibiting  within  its 
jurisdiction  the  sale  of  liquor  over  the  l)ar  or  in  stores 
in  (luantities  under  forty  liters.  Retail  licenses  in 
limited    number  —  according    to    population  —  are 


THE  PRACTICE  OF  PSYCHIATRY.  203 

awarded  by  the  municipal  authorities  at  pubUc  sale 
to  the  highest  bidder,  provided  he  be  a  person  of 
good  reputation.  The  law  provides  further  that 
retail  licenses  may  be  awarded  to  societies,  thus 
making  it  possible  for  public-spirited  citizens  to 
form  organizations  for  the  purpose  of  securing  the 
licenses  which  are  at  the  disposal  of  the  municipal 
authorities  and  thus  assuming  control  of  the  entire 
retail  liquor  trade.  Thus  was  founded  for  the  first 
time  in  the  city  of  Gothenburg  ''The  Gothenburg 
Retail  Liquor  Stock  Company,"  This  and  other 
similar  companies  derive,  of  course,  no  profit  from 
the  trade,  the  profits  going  in  part  (60-80%)  into 
the  city  treasury  and  in  part  (20-40%)  into  the 
state  treasury.  The  aim  of  such  companies,  in 
contrast  with  that  of  private  liquor  dealers,  is  to 
reduce  the  consumption  of  liquors;  for  that  purpose 
they  have  established  popular  price  restaurants, 
reading  rooms,  etc.,  for  working  people. 

This  system  is  imperfect  in  that  it  fails  to  control 
the  sale  of  fermented  beverages,  affecting  only  that 
of  distilled  liquors.  However,  a  special  investigating 
committee  appointed  by  the  municipal  authorities  of 
Gothenburg  in  1899  has  recommended  the  extension 
of  the  system  to  embrace  the  control  of  beer  saloons. 

In  spite  of  the  shortcomings  of  this  system,  which 
are  more  easily  pointed  out  than  remedied,  it  stands 
as  the  most  effective  and  most  practical  system  that 
has  yet  been  devised,  as  the  following  results  will 
show.^ 

^  A.  Baer  and  B.  Laquer.  Die  Trunksucht  und  ihre  Abwehr. 
Berlin  and  Vienna,  1907. 


204  MANUAL  OF  PSYCHIATRY. 

Prior  to  1855  liquor  could  be  purchased  in  Sweden 
almost  in  any  cottage.  In  1869  there  was  only  one 
barroom  or  liquor  store  to  8028  inhabitants;  in  1880 
only  one  to  13,450  inhabitants. 

There  are  2400  separate  municipaUties  in  Sweden; 
of  these  1800  have  entirely  abolished  barrooms  and 
retail  liquor  stores. 

The  consumption  of  liquor  in  Sweden  in  1824  was 
46  liters  per  capita,  in  1851  it  was  22  liters,  and  in 
1896  it  had  become  reduced  to  7.2  liters. 

Prior  to  enactment  of  the  laws  of  1855  from  25% 
to  30%  of  all  male  cases  admitted  to  hospitals  for  the 
insane  were  due  to  intemperance.  Following  the 
enactment  of  those  laws  this  percentage  gradually 
became  less,  and  from  1865  until  1899  it  varied  be- 
tween 5.2%  and  7.19%. 

It  should  be  added  here  tl  at  recent  statistics  from 
other  countries  show  that  the  percentage  of  cases  of 
insanity  in  which  alcoholism  is  the  cause  approaches 
that  of  the  older  Swedish  statistics:  State  of  New 
York,  31.4%;!  State  of  Massachusetts,  30.6%;2 
Staffordshire  County,  England,  26.3%;^  Lower  Aus- 
tria, 24.9%.^ 

The  introduction  of  the  Gothenburg  system  into 


'  Report  of  the  State  Commission  in  Lunacy  ior  the  year  ending 
Sept.  30,  1909. 

2  I'Voni  rei)orts  of  the  state  hospitals  at  Tewkshury,  Taunton, 
Worcester,  Westboro,  Northampton,  and  Danvers  for  the  year 
encUii;;  Nov.  30,  1906. 

^  Report  of  Staffordshire  County  Council  for  the  year  1904. 

*  Bericht  des  Niedenisterreichischen  Ijjindi'Siiusschasses  iiber 
Bcine  Amtswirksanikeit  vom  1.  JuU  1902  bis  30.  Juni  1903. 


THE  PRACTICE  OF  PSYCHIATRY.  205 

Norway  and  into  Finland  has  been  followed  by  results 
similar  to  those  obtained  in  Sweden. 

Prohibition  has  been  tried  in  several  states.  In 
some  of  these  states  the  prohibition  laws  have  been 
repealed  (Connecticut,  Vermont,  Massachusetts);  in 
others  they  have  been  but  recently  enacted  (Ala- 
bama, Georgia,  Oklahoma) ;  in  still  others  they  have 
been  in  force  for  many  years  (in  Maine  since  1851, 
in  Kansas  since  1880,  in  North  Dakota  since  1889), 
so  that  they  may  be  assumed  to  have  been  given  a 
thorough  practical  trial. 

It  must  be  observed  that  owing  to  the  operation  of 
the  Interstate  Commerce  Law  a  state  cannot  pro- 
hibit the  importation  of  liquors  from  other  states. 
This  circumstance  together  with  the  practical  diffi- 
culties of  enforcing  prohibition  laws  reduces  mate- 
rially the  possible  effectiveness  of  such  laws. 

Nevertheless  it  has  been  amply  shown  that  crime 
and  pauperism  have  been  reduced  wherever  prohi- 
bition laws  have  been  enacted.^ 

Unfortunately  the  effect  upon  insanity  is  not  so 
obvious.  We  find  that  in  the  State  of  Maine  21.4% 
of  all  male  cases  admitted  to  the  hospitals  for  the 
insane  (not  counting  the  cases  in  which  the  causes 
were  unascertained)  are  due  to  alcoholism,  ^  —  a 
figure  which  is  but  slightly  below  those  of  Hcense 


^  Year  Book  of  the  Aiiti-Saloon  League,  1908.  —  Twenty-sixth 
Annual  Report  of  the  Massachusetts  Bureau  of  Labor.  Boston, 
1806.  —  Twenty-seventh  Annual  Report  of  the  Massachusetts  State 
Board  of  Charities,  1907. 

2  Reports  of  the  Maine  Insane  Hospitals  for  the  year  ending 
Nov.  30,  1909. 


206  MANUAL  OF  PSYCHIATRY. 

states.  It  is  clear  that  this  sHght  difference  may 
possibly  be  due  not  to  prohibition  but  to  other 
causes. 

Local  option  seems  to  be  a  much  more  popular 
measure  than  state  prohibition.  It  is  estimated  that 
only  10%  of  the  population  of  the  United  States  is 
Uving  under  state  prohibition,  while  more  than  75% 
is  living  under  local  option,  and  that  over  40%  of 
those  living  under  local  option  are  in  ''dry"  terri- 
tory.^ 

Thus -local  option,  as  compared  with  prohibition, 
seems  to  possess  the  advantage  of  being  more  accept- 
able to  most  communities  and  therefore  more  prac- 
ticable. 

The  effect  of  no  Ucense  under  local  option  is  similar 
to  that  of  prohibition;  that  is  to  say,  drunkenness, 
crime,  and  pauperism  are  undoubtedly  reduced,  but 
the  incidence  of  insanity  is  but  slightly,  if  at  all, 
affected. 

The  following  table  shows  the  reduction  of  drun- 
kenness which  resulted  from  no  license  under  local 
option  in  several  cities  in  Massachusetts. 

It  seems  strange  that  in  the  world  campaigns 
against  syphilis  there  should  have  been  until  re- 
cently complete  neglect  of  measures  which  have 
Ijeen  so  successful  in  the  prevention  of  other  com- 
municable diseases,  namely,  the  compulsory  report- 
ing of  all  cases,  regardless  of  the  manner  or  source 
of  infection,  and  their  hospitalization,  if  necessary, 
during  the  periods  of  greatest  infectiousness. 

*  Year  Book  of  the  Anti-Saloon  League,  1908. 


THE  PRACTICE  OF  PSYCHIATRY. 


207 


Arrests  for  Drunkenness. 

Cities. 

License. 

No  License. 

Year. 

Number 
of  Ar- 
rests. 

Year. 

Number 
of  Ar- 
rests. 

Brockton 

1898 
1900 
1901 
1902 
1901 
1902 
1903 
1903 
1905 

1627 

634 

1202 

1246 

673 

4077 

1432 

842 

1160 

1899 
1901 
1900 
1901 
1902 
1903 
1904 
1904 
1906 

455 

Waltham 

179 

Taunton 

482 

Chelsea 

398 

Newburyport 

150 

Lowell 

2304 

Salem 

503 

Woburn 

204 

Fitchburg 

359 

Local  inunction  with  calomel  ointment  applied 
within  an  hour  or  even  within  several  hours  of  ex- 
posure to  the  infection  may  prevent  the  develop- 
ment of  syphilis.^ 

For  the  prevention  of  hereditary  syphilis  Fournier 
gives  the  following  rule:  ''When  a  woman  is  preg- 
nant with  a  child  threatened,  by  paternal  anteced- 
ents, with  syphilitic  heredity,  syphilitic  treatment 
of  the  mother,  although  healthy,  constitutes  for  this 
child  a  real  and  powerful  safeguard  for  which  there  is 
a  precise  and  formal  indication. "  ^ 

Finally  there  can  be  no  doubt  that  in  cases  of 


1  Articles  by  L.  W.  Harrison  and  C.  N.  Fiske  in  A  System  of 
Syphilis,  edited  by  Power  and  Murphy.  London,  1910.  Vol.  VI, 
pp.  137  and  308.  —  M.  F.  Gates.  The  Prophijlaxis  of  Gonorrhoea. 
Tlie  Therapeutic  Gazette,  Jan.,  1911. 

2  Fournier.  The  Treatment  and  Prophylaxis  of  Syphilis.  Eng- 
lish translation  by  C.  F.  MarshaU.     New  York,  1907.     P.  447. 


208 


MANUAL  OF  PSYCHIATRY. 


syphilitic  infection  promptness  and  thoroughness  of 
treatment,  until  the  Wassermann  reaction  becomes 
and  remains  negative  as  shown  by  repeated  exami- 
nations at  intervals  of,  say,  a  month,  is  capable  of 
greatly  reducing  or  even  eliminating  the  danger  of 
involvement  of  the  nervous  system. 

Head  injuries.  —  There  is  but  little  to  be  said 
with  reference  to  head  injuries  which,  like  other 
injuries  resulting  in  either  disability  or  death,  have 
become  common  as  a  result  of  the  great  modern 
development  of  industries,  means  of  transportation, 
etc.  It  may  be  pointed  out,  however,  that  in  the 
United  States,  owing,  probably,  to  imperfect  legis- 
lative protection,  serious  accidents  are  needlessly 
frequent,  as  may  be  judged  from  the  example  fur- 
nished by  American  and  British  railroad  statistics. 
These,  for  the  year  1906,^  are  given  in  the  following 
table. 


Total  number  of  passengers  carried.  . 

Total  miles  of  track 

Number  of  collisions  and  derailments 

Number  of  passengers  killed 

Number  of  passengers  injured 

Number  of  employees  killed 

Number  of  employees  injured 


American 
Railroads. 


soo.ooo.ooo 

200,000 

13,455 

M6 

6,000 

S70 
7,483 


British 
Railroads. 


1,200.000,000 

27,000 

239 

58 

631 

13 

140 


The  individual.  —  It  has  already  been  said  that  an 
individual  who  comes  from  normal  stock,  abstains 


'  J.   O.   I'agan.     Confessions  of  a  Railroad  Sianalman.     Boston 
and  New  York,  1908. 


THE  PRACTICE  OF   PSYCHIATRY.  209 

from  alcohol,  is  free  from  syphilis,  and  escapes  acci- 
dental head  injury  is  not  threatened  with  mental 
alienation. 

It  is  not  so  with  the  neuropathic  individual:  for 
him  every  feature  of  life  in  society  presents  possible 
dangers.  From  childhood  up  the  adjustment  be- 
tween him  and  his  environment  must  be  nicely  con- 
trolled if  the  danger  of  a  mental  breakdown  is  to  be 
minimized;  his  bringing-up  at  home,  his  education 
at  school,  his  sexual  Hfe,  his  career,  his  social  and 
family  relations  are  great  matters  for  special  adjust- 
ment, particularly  with  the  ends  in  view  of  proper 
habit  training,  avoidance  of  the  incidental  causes 
referred  to  in  the  chapter  on  Etiology  as  possessing 
quasi-specific  potency  in  the  production  of  mental 
ahenation,  and  prompt  institution  of  treatment  upon 
the  appearance  of  any  symptoms. 

Immigration.  —  The  importance  for  this  country 
of  immigration  in  connection  with  the  problems  of 
the  prevalence  and  prevention  of  insanity  has  al- 
ready been  pointed  out  in  the  chapter  on  Etiology. 
Although  the  conclusion  has  been  drawn  that  there 
is  no  evidence  to  show  that  there  is  a  greater  prone- 
ness  toward  mental  disease  in  the  foreign-born  than 
in  the  native  population,  this  is  not  to  be  construed 
as  arguing  in  favor  of  relaxing  the  efforts  of  keeping 
out  all  insane  and  otherwise  mentally  defective 
immigrants;  on  the  contrary,  whether  insanity  be 
relatively  frequent  or  rare  among  immigrants,  the 
welfare  of  this  country  demands  that  insane  persons 
be  prevented  from  entering  and  remaining  in  it 
and  that  the  facilities  for  their  detection  and  de- 


210  MANUAL  OF  PSYCHIATRY. 

portation  be  perfected  and  increased  rather  than 
reduced.  On  the  other  hand,  a  pohcy  of  general 
restriction  of  immigration,  such  as  has  been  advo- 
cated by  some,  would  seem  to  be  unnecessary  and 
unjustified  as  far  as  the  interests  of  eugenics  and 
mental  hygiene  in  this  country  are  concerned. 

Medico-legal  questions.  —  The  most  important 
medico-legal  questions  that  may  arise  in  connection 
with  cases  of  alleged  mental  disorders  are  those  of 
necessity  of  commitment,  competence  in  the  man- 
agement of  one's  own  affairs,  testamentary  capacity, 
and  criminal  responsibility.  The  mere  fact  of  the 
existence  of  a  mental  disorder,  estabUshed  by  a 
medical  diagnosis,  is  not  sufficient  to  settle  these 
questions. 

The  question  of  necessity  of  commitment  has  already 
been  touched  on  in  the  preceding  chapter.  The 
tendency  in  leading  states  is  to  limit  as  far  as  possible 
the  practice  of  committing  cases  allowing  any  suit- 
able case  to  be  admitted  to  the  institutions  for  the 
insane  on  voluntary  application,  at  any  tune,  with- 
out special  formality. 

Psychiatrists  are  looking  forward  to  even  greater 
facility  of  obtaining  treatment  for  cases  of  mental 
derangement  in  the  future  in  psychopathic  wards 
to  be  established  in  connection  with  general  hos- 
pitals: ''The  details  of  transfer  from  the  psycho- 
pathic ward  to  the  large  state  institutions  should 
be  made  as  simple  as  possible.  Transfer  should  be 
made  effective  on  a  certificate  of  two  properly 
qualified  physicians  and  the  matter  should  not  have 
to  come  into  court  at  all  unless  it  is  brought  there 


THE  PRACTICE  OF  PSYCHIATRY.  211 

by  the  patient,  his  relatives,  or  some  friends  on  his 
behalf.  I  would  not  close  the  courts  to  the  so-called 
insane  by  any  means,  but  I  would  not  insist  on  a 
legal  process,  whether  the  patient  wanted  it  or  not; 
I  would  not  insist,  so  to  speak,  on  cramming  an 
alleged  constitutional  right  down  the  patient's 
throat  at  the  expense  of  his  life.  We  see  to-day  this 
process  of  commitment  going  on  where  nobody 
wants  it.  The  patient  does  not  want  it,  the  patient's 
friends  and  relatives  do  not  want  it,  and  anybody 
who  stands  and  watches  it  proceed  recognizes  on  the 
face  of  it  that  it  is  a  farce.  I  would,  therefore,  pro- 
ceed in  the  matter  of  commitment  in  the  simplest 
way.  Leave  the  courts  accessible  to  the  patient 
if  he  wants  to  appeal  for  relief,  and  it  will  be  sur- 
prising how  rare  such  appeals  will  be."  ^ 

As  regards  competence  in  the  management  of  one's 
own  affairs  and  testamentary  capacity,  no  difficulty  is 
experienced  in  the  majority  of  cases  of  pronounced 
mental  disorder;  difficulty  is  met  with  rather  in 
connection  with  milder  cases  in  which  there  may  be 
room  for  legitimate  difference  of  opinion.  In  cases 
in  which  a  direct  examination  of  the  person  whose 
mentality  is  in  question  is  not  practicable,  the  opin- 
ion of  a  psychiatrist  is  of  but  little  more  value  than 
that  of  a  lay  person ;  in  such  cases  it  would  seem  best 
to  place  the  burden  of  proof  on  those  who  allege  in- 
competence or  limited  testamentary  capacity,  and  to 
require  as  proof  not  merely  opinion,  however  expert, 
but  instances  of  actual  business  mismanagement  of 

^  Wm.  A.  White.  Dividing  Line  between  General  Hospital  and 
Hospital  for  Insane.     The  Modem  Hospital,  March,    1914. 


212  MANUAL  OF  PSYCHIATRY. 

obviously  abnormal  degree  or  nature.  Where  there 
is  opportunity  for  direct  examination  the  testimony 
of  a  psychiatrist  may  be  of  determining  value,  mainly 
for  the  reason  that  he  is  better  able  than  a  layman  to 
establish  or  eliminate,  as  the  case  may  be,  the  ex- 
istence of  defects  of  memory,  judgment,  affectivity, 
etc.,  which  would  have  a  bearing  on  the  question  at 
issue;  here  again  facts,  as  revealed  by  the  examina- 
tion, rather  than  opinions,  however  expert,  will  be 
of  greatest  assistance  to  the  judicial  authorities  in 
drawing  a  just  conclusion.  It  need  hardly  be  said 
that  here,  as  under  other  conditions,  the  testimony 
of  witnesses,  including  expert  witnesses,  is  of  value 
according  to  the  degree  of  freedom  from  bias.  It 
is,  of  course,  not  legal  for  a  court  to  rule  out  the 
testimony  furnished  by  witnesses  retained  either  by 
the  plaintiff  or  by  the  defendant;  but  it  is  possible, 
and  desirable  for  the  cause  of  justice,  for  the  court 
to  call  experts  in  order  to  be  sure  of  securing  testi- 
mony that  is  free  from  even  unconscious  bias. 

A  psychiatrist  called  as  an  expert  ought  by  right 
to  refrain  from  giving  an  opinion  on  the  main  ques- 
tion at  issue,  that  of  competence  or  testamentary 
capacity,  that  being,  strictly  speaking,  not  a  medical 
or  scientific  question  at  all,  but  a  question  of  common 
sense  for  the  court  to  detennine.  The  data  revealed 
by  his  examination  and  his  judgment  of  their  path- 
ological significance  are  all  that  he  can  contribute 
as  an  expert;  an  opinion  on  competence  or  testa- 
mentary capacity  that  might  be  elicited  from  him 
should  not  be  considered  as  being  of  greater  value 
than  one  offered  by  anyone  else. 


THE  PRACTICE   OF  PSYCHIATRY.  213 

Perhaps  the  most  difficult  position  in  which  a 
psychiatrist  may  find  himself  is  when  he  is  consulted 
on  the  question  of  criminal  responsibility.  Here  the 
difficulty  Ues  not  so  much  in  the  nature  of  the 
question  as  in  the  difference  between  the  current 
legal  and  the  scientific  conceptions  of  responsibility. 

The  current  legal  conception  is  based  on  the  meta- 
physical theory  of  freedom  of  the  will;  the  individual 
must  exercise  his  will  under  the  guidance  of  ethical 
principles;  he  is  responsible  for  his  acts  unless, 
owing  to  immaturity  or  mental  disease,  he  is  in- 
capable of  distinguishing  right  from  wrong  and  is 
thus  bereft  of  proper  guidance;  when  no  such  in- 
capacity can  be  shown  he  must  undergo  punishment 
in  proportion  to  the  gravity  of  his  crime;  this  pun- 
ishment or  retribution,  which  is  nothing  but  a 
systematization  of  the  original  impulse  of  revenge, 
is  now  most  frequently  justified  as  a  deterrent 
measure;  by  instilling  a  fear  of  similar  punishment, 
it  is  supposed,  society  protects  itself  against  repeti- 
tions of  the  crime;  under  the  influence  of  this  fear 
responsible  persons,  i.e.,  those  capable  of  distinguish- 
ing right  from  wrong,  will  refrain  from  doing  wrong. 

The  psychiatrist,  when  consulted  in  a  criminal 
case,  is  not  asked  to  state  in  a  general  way  whether 
or  not  in  his  opinion  the  accused  is  insane,  but 
whether  he  is  insane  in  the  special  legal  sense  with 
reference  to  criminal  responsibility,  i.e.,  incapable  of 
distinguishing  right  from  wrong. 

The  scientific  conception  of  responsibility  is,  of 
course,  very  different;  the  metaphysical  theory  of 
freedom  of  the  will  has  no  place  in  science;    the 


214  MANUAL  OF  PSYCHIATRY. 

phenomena  of  the  will,  hke  other  natural  phenomena, 
are  subject  to  natural  laws  and  are  determined  by 
antecedents,  such  as  heredity,  education,  various 
environmental  influences,  and  events  inmaediately 
preceding  a  given  act  under  consideration,  that  is  to 
say,  factors  for  the  most  part  beyond  the  control  of 
the  individual;  responsibility,  therefore,  in  the  sense 
of  Uabihty  to  profitless  suffering  in  retribution  for 
wrongdoing,  does  not  exist  scientifically  in  any  case, 
sane  or  insane. 

On  the  other  hand,  everybody,  sane  or  insane,  is 
responsible  in  the  sense  of  being  liable  to  forfeit  his 
liberty,  property,  or  the  results  of  his  labor  when 
necessary  for  the  protection  of  the  rights  of  others 
or  for  the  restoration  of  damage  caused  by  him. 

It  is  true  that  the  tendency  of  modern  times  is  to 
ehminate  as  far  as  possible  the  element  of  retribution 
in  the  treatment  of  crime;  yet  the  object  of  a  court 
proceeding  in  a  criminal  case  is  to-day  still  the  de- 
tennination  of  the  degree  of  guilt  of  the  accused,  i.e., 
of  the  amount  of  punishment  to  which  he  should  be 
sentenced.  As  long  as  such  is  the  case,  it  seems  to 
us,  psychiatrists  cannot  consistently  take  part  in 
the  proceeding.  They  can  assist  only  in  a  scientific 
investigation  of  a  case  of  crime  for  the  purpose  of 
determining  its  complex  of  causes,  as  far  as  it  may 
be  possible  to  do  so,  and  of  thus  gaining  guidance 
for  measures  of  prevention,  such  as  temporary  or 
permanent  segregation,  etc.  The  object  of  the 
court  proceeding,  from  such  a  point  of  view,  should 
be  to  determine  whether  or  not  the  accused  has 
committed  the  crime  as  alleged  and,  if  so,-  the  amount 


THE   PRACTICE  OF  PSYCHIATRY.  215 

of  damage  as  well  as  it  can  be  estimated  in  terms  of 
money  value  and  the  extent  to  which  it  is  possible 
for  the  damage  to  be  made  good  either  by  attaching 
the  property  of  the  author  of  the  crime  or  by  a 
judgment  against  the  products  of  his  labor. 

The  scientific  attitude  in  relation  to  the  question 
of  criminal  responsibility  would  eliminate  the  in- 
centives for  the  troublesome  plea  of  insanity  in 
criminal  cases,  on  the  one  hand,  by  ignoring  the 
question  of  guilt  and,  on  the  other  hand,  by  enforcing 
a  responsibihty  for  damage  in  all  cases,  sane  or 
insane. 

The  almost  exclusive  preoccupation  of  criminal 
courts  with  the  questions  of  guilt  and  punishment 
has  led  to  their  overlooking  largely  the  important 
relationship  which  there  is  between  vice  and  crime 
and  mental  defectiveness.^  The  evidence  of  such 
a  relationship  between  prostitution  and  mental  de- 
fectiveness has  already  been  given  in  the  preceding 
section  of  this  chapter,  in  connection  with  the  dis- 
cussion of  the  prophylaxis  of  syphilis. 

Equally  striking  is  the  evidence  of  the  relation- 
ship which  exists  between  mental  disorders  and 
crime.  As  regards  feeble-mindedness  alone,  for  in- 
stance, Goddard^  cites  the  following  statistics  of  per- 
centages of  defectives  found  in  various  reformatories 
and  institutions  for  delinquents  b}/  the  systematic 
application  of  Binet  tests:  Rahway  Reformatory, 
New  Jersey,  46;    Geneva,  Illinois,  89;    Ohio   Boys' 

^  A.  J.  Rosanoff.  A  Program  of  Psychiatric  Progress.  Med. 
Record,  Feb.  20,  1915. 

2  H.  H.  Goddard.     Feeble-mindedness.     New  York,  1914. 


216  MANUAL  OF  PSYCHIATRY. 

School,  70;  Ohio  Girls'  School,  70;  Virginia,  three 
reformatories,  79. 

The  statistics  of  the  United  States  Census  per- 
taining to  insanity  and  crime  are  also  of  interest 
in  this  connection. 

The  States  of  this  country  may  be  divided  into 
two  groups  according  to  the  number  of  inmates  in 
insane  hospitals  in  proportion  to  the  general  popula- 
tion. Since,  for  the  present  purpose,  this  is  done 
to  facilitate  the  study  of  the  relationship  which  ex- 
ists between  crime  and  insanity,  it  would  seem  best 
to  take  into  consideration  only  the  male  population 
at  large  and  the  male  asylum  and  prison  inmates: 
crime  is  not  nearly  so  common,  whether  as  a  neuro- 
pathic manifestation  or  otherwise,  among  women  as 
among  men,  the  counterpart  among  women  being 
sexual  immorality,  prostitution,  illegitimacy,  etc. 

The  first  group  of  states,  comprising  Alabama, 
Arkansas,  Colorado,  Florida,  Georgia,  Idaho,  Louisi- 
ana, Mississippi,  New  Mexico,  North  Carolina, 
North  Dakota,  Oklahoma,  South  Carolina,  Tennes- 
see, Texas,  Utah,  West  Virginia,  and  Wyoming,  has 
a  total  male  population  10  years  of  age  or  over  of 
9,705,527;  each  of  these  states  has  less  than  200 
male  asylum  inmates  per  100,000  of  the  male  popu- 
lation 10  years  of  age  or  over,  the  average  for  the 
entire  group  being  140.9. 

In  this  group  of  states  the  number  of  inmates  in 
prisons,  penitentiaries,  jails,  and  workhouses,  not 
including  juvenile  delinquents,  is  31,290,  i.e.,  322.4 
per  100,000  of  the  general  population  10  years  of 
age  or  over. 


THE   PRACTICE  OF  PSYCHIATRY.  217 

The  second  group  of  states,  comprising  Arizona, 
California,  Connecticut,  Delaware,  Illinois,  Indiana, 
Iowa,  Kansas,  Kentucky,  Maine.  Maryland,  Massa- 
chusetts, Michigan,  Minnesota,  Missouri,  Montana, 
Nebraska,  Nevada,  New  Hampshire,  New  Jersey, 
New  York,  Ohio,  Oregon,  Pennsylvania,  Rhode  Is- 
land, South  Dakota,  Vermont,  Virginia,  Washington, 
and  Wisconsin,  has  a  total  male  population  10  years 
of  age  or  over  of  27,190,148;  each  of  these  states 
has  more  than  200  male  asylum  inmates  per  100,000 
of  the  male  population  10  years  of  age  or  over,  the 
average  for  the  entire  group  being  304.7. 

In  this  group  of  states  the  number  of  inmates  in 
prisons,  penitentiaries,  jails,  and  workhouses,  not 
including  juvenile  delinquents,  is  71,482,  i.e.,  262.9 
per  100,000  of  the  general  population  10  years  of 
age  or  over. 

The  contrast  between  the  two  groups  of  states  as 
regards  the  relative  number  of  prisoners  is  suffi- 
ciently striking  as  revealed  by  the  census  statistics. 
But  it  is  probable  that  the  excess  of  crime  in  the 
first  group  of  states  is  but  partly  revealed  in  these 
statistics;  for  it  seems  reasonable  to  assume  that 
the  facilities  for  the  detection  and  prosecution  of 
crime  are  in  these  states,  Hke  other  social  institu- 
tions, inferior  as  compared  with  those  of  the  second 
group  of  states,  so  that  a  greater  amount  of  crime 
remains  undetected,  and  unrepresented  in  the  statis- 
tics of  penal  institutions. 

However  this  may  be,  it  seems  certain  that  the 
inadequacy  of  the  provisions  for  the  care  and  cus- 
tody of  cases  of  mental  disorder  in  the  first  group 


218  MANUAL  OF  PSYCHIATRY. 

of  states,  regarded  from  its  financial  aspect  alone, 
does  not  cany  with  it  the  advantage  of  economy, 
for  what  may  be  saved  in  expenditures  for  the  main- 
tenance of  the  insane  is  lost  in  increased  expendi- 
tures for  the  maintenance  of  convicted  criminals; 
it  is,  indeed,  not  unlikely  that  the  loss  is  far  greater 
than  the  saving. 

To  give  the  student  a  more  direct  view  of  the 
evidence  showing  a  relationship  between  crime  and 
mental  disorders  we  could  do  no  better  than  to  quote 
from  a  report  prepared  by  Dr.  Anne  Moore,  in  which 
several  pages  are  devoted  to  a  consideration  of  the 
crime  of  arson. ^ 

"Arson  is  a  common  crime  among  the  feeble- 
minded. .  -  .  Many  times  thousands  of  dollars' 
worth  of  property  are  destroyed  and  many  lives  en- 
dangered before  legal  proof  of  guilt  is  estabhshed. 
On  conviction  these  persons  are  often  committed  to 
penal  institutions,  only  to  be  paroled  and  set  free 
to  repeat  the  crime;  or  they  are  left  to  serve  long 
sentences  which  on  their  release  do  not  act  as  a 
deterrent.  The  Fire  Marshal  of  New  York  City 
tells  me  that  a  sufficient  number  of  cases  of  pyro- 
mania  have  come  to  his  attention  to  fill  a  special 
institution.  Two  cases  have  come  to  my  knowledge 
in  which  feeble-minded  children  have  set  fire  to  the 
clothing  of  other  children  with  fatal  consequences. 

"Between  the  dates  of  February  1,  1910  and  July 
12,    1910,    sixteen    fires    occurred    in    the    district 

1  The  FcMc-minded  in  Ncic  York.  A  report  prepared  for  the 
Public  Efhication  Association  of  New  York  by  Anne  Moore.  New 
York,  1911. 


THE  PRACTICE  OF  PSYCHIATRY.  219 

bounded  by  Fifth  and  Lexington  avenues  and  108th 
and  119th  streets,  all  in  twenty-family,  five-story 
tenements,  and  all  of  similar  incendiary  origin. 
These  fires  were  traced  to  a  feeble-minded  youth 
who  had  no  motive  for  the  deed  except  a  desire  for 
excitement.  When  he  visited  one  of  the  buildings 
to  deliver  goods  his  method  was  to  Ught  a  bundle 
of  papers  which  he  had  previously  saturated  with 
kerosene  from  a  bottle  which  he  carried  with  him, 
and  leave  them  in  the  hallway,  in  a  corner  of  the 
stairway,  or  in  the  cellar.  He  was  caught  and  con- 
victed on  the  sixteenth  fire.  He  was  declared  in- 
sane and  is  now  confined  in  the  Central  IsHp  State 
Hospital. 

''A  feeble-minded  man,  25  years  of  age,  started 
45  fires  within  three  months.  The  loss  was  esti- 
mated at  a  quarter  of  a  million  dollars.  He  usually 
left  something  burning  in  the  airshaft  or  wood-bin. 
At  his  trial  he  was  declared  sane  and  was  sent  to 
Elmira.  After  13  months  he  was  released  on  parole 
and  won  his  absolute  release. 

''A  feeble-minded  boy,  living  in  Massachusetts, 
set  fire  to  his  grandfather's  house.  He  saved  him- 
self by  jumping  from  the  upper  window  into  a 
cherry  tree.  Afterwards,  he  set  fire  to  a  stable  in 
Gloucester,  Mass.,  and  was  sent  to  a  reform  school 
for  two  and  a  half  years.  After  his  release  he  set 
on  fire,  one  by  one,  a  row  of  houses  owned  by  dif- 
ferent clergymen,  called  'holy  row.'  Later  he 
burned  a  house  belonging  to  the  father  of  the  dis- 
trict attorney,  was  caught,  and  convicted.  He  spent 
four  years  in  Charlestown  Prison.     He  became  re- 


220  MANUAL  OF  PSYCHIATRY. 

ligious  and  was  paroled  on  condition  that  he  go  to 
another  state.  He  came  to  New  York  and  for  a 
time  was  under  Mrs.  Booth's  care.  Afterwards  he 
set  fire  to  a  barn  and  to  the  Bayside  Yacht  Club. 
He  was  caught  and  convicted.  He  is  now  in  Sing 
Sing. 

''What  this  means  in  money  may  be  gathered 
from  following  the  evidence  and  proceedings  in  any 
case  of  arson,  a  common  crime  among  mental  de- 
fectives. 

"(1)  A  building  is  set  on  fire  with  attendant  dan- 
ger to  its  dwellers,  and  loss  of  property  to  them  and 
the  owner. 

"(2)  The  fire  department  is  called  out.  Usually 
six  companies,  involving  one  battalion  chief,  72 
men,  4  engines,  and  2  trucks,  the  police  reserves, 
usually  about  20  men,  and  an  insurance  fire  patrol 
wagon  with  an  officer  and  10  men,  respond  to  an 
alarm. 

"(3)  The  offender  is  arrested  by  a  police  officer, 
after  examination  of  material  witnesses  by  a  fire 
marshal. 

"(4)  After  being  taken  to  the  station  house  the 
incendiary  must  go  before  the  magistrate;  and  if 
brought  to  trial,  with  its  attendant  delays,  much 
time  of  many  different  salaried  officers  is  consumed 
as  well  as  that  of  the  material  witnesses. 

"(5)  After  conviction  and  before  sentence  is 
passed  a  probation  officer  may  l)e  asked  to  look  into 
the  history  of  the  case,  which  will  take  at  least  a 
week.  The  sentence  may  be  any  length  of  time,  up 
to  40  years. 


THE  PRACTICE  OF  PSYCHIATRY.  221 

"All  this  expensive  machinery  need  not  have  been 
used  in  the  case  of  feeble-minded  incendiaries  if 
they  had  been  cared  for  in  institutions  at  the  proper 
time. " 


PART  II. 

SPECIAL  PSYCHIATRY. 

CLASSIFICATION. 

Thirteen  years  ago,  when  the  first  French  edition 
of  this  Manual  was  pubhshed,  the  author  felt  it 
incumbent  on  himself  to  offer  a  sort  of  apology  for 
following  Kraepelin's  classification  of  mental  dis- 
orders. Since  then  this  classification  has  largely 
supplanted  all  others  throughout  the  world,  so  that 
to-day  an  apology  seems  no  longer  necessary.  We 
have,  however,  changed  the  arrangement  of  the 
chnical  groups,  placing  them  in  an  order  as  far  as 
possible  according  to  etiology. 

I.   Constitutional  disorders: 

Idiocy,  imbecility,  and  feeble-mindedness. 
Epileptic  psychoses. 
Dementia  prsecox. 
Paranoia. 

Manic-depressive  psychoses. 
Involutional  melancholia. 
Other  psychopathic  conditions. 
Huntington's  chorea. 

II.   Alcoholic  disorders: 

Pathological  drunkenness. 
Delirium  tremens. 

223 


224  MANUAL  OF  PSYCHIATRY. 

Acute  hallucinosis. 

Delusional  states. 

The  polyneuritic  psychosis. 

Dementia 

III.  Syphilitic  disorders: 

General  paresis. 
Cerebral  syphilis. 
Cerebral  arteriosclerosis. 

IV.  Traumatic  disorders. 

Delirium. 

Neurasthenic  states. 
Epilepsy. 
Dementia. 

V.  Miscellaneous  groups: 

Infective,  exhaustive,  toxic,  autotoxic,  thyro- 
genic,  organic,  and  senile. 


CHAPTER  I. 

ARRESTS  OF  DEVELOPMENT :  IDIOCY,  IMBECILITY, 
AND  FEEBLE-MINDEDNESS. 

Etiology.  —  Bad  heredity  is  by  far  the  most  com- 
mon and  important  cause  of  arrests  of  development. 
There  are,  however,  other  factors  acting  during 
intra-uterine  hfe  or  in  infancy  or  early  childhood 
which  may  cause  them;  two  of  these  deserve  special 
mention,  parental  alcoholism  and  parental  syphilis. 

Alcoholism  in  all  its  forms  is  encountered  in  the 
parents  of  idiots  and  imbeciles:  chronic  alcoholism, 
drunkenness  at  the  moment  of  conception  or  during 
pregnancy,  etc.  Statistics  compiled  by  Bourneville 
show  that  48%  of  idiots  and  imbeciles  are  the  off- 
spring of  alcoholic  parents. 

These  figures  correspond  approximately  to  those 
published  by  most  other  authors.  Yet  the  question  of 
the  effect  of  parental  alcoholism  upon  the  offspring 
cannot  be  said  to  have  been  fully  answered.  The 
fact  that  a  large  percentage  of  the  parents  of  defec- 
tive children  are  alcoholic  lacks  significance  in  view 
of  the  great  general  prevalence  of  alcohohsm  and  in 
the  absence  of  accurate  data  concerning  the  frequency 
of  alcoholism  in  the  parents  of  normal  children. 
Further,  there  is  some  evidence  which  suggests  that 
alcoholism  is  often  but  a  symptom  of  neuropathic 
constitution,  so  that  abnormal  traits  in  the  offspring 

225 


226  MANUAL  OF  PSYCHIATRY. 

of  alcoholic  parents  may  possibly  be  attributable  to 
inheritance  of  the  neuropathic  taint  rather  than  to 
the  injurious  effect  of  alcohol  upon  the  germ  plasm. 
Unfortunately  statistics  bearing  upon  this  important 
subject  have  not  always  been  very  critically  exam- 
ined. 

In  a  recent  memoir  from  the  Francis  Galton 
Laboratory  for  National  Eugenics,  University  of 
London,^  consisting  of  a  careful  and  apparently 
trustworthy  statistical  research  of  this  subject,  we 
find,  among  others,  the  following  conclusions: 

**  There  is  a  higher  death  rate  among  the  offspring 
of  alcohohc  than  among  the  offspring  of  sober 
parents. 

''Owing  to  the  greater  fertility  of  alcoholic  parents, 
the  net  family  of  the  sober  is  hardly  larger  than  the 
net  family  of  the  alcoholic. 

"The  general  health  of  the  children  of  alcoholic 
parents  appears  on  the  whole  slightly  better  than 
that  of  the  children  of  sober  parents.  There  are  fewer 
delicate  children  and  in  a  most  marked  way  cases 
of  tuberculosis  and  epilepsy  are  less  frequent  than 
among  the  children  of  sober  parents. 

"Parental  alcoholism  is  not  the  source  of  mental 
defect  in  offspring. 

"The  relationship,  if  any,  between  parental  alco- 
holism and  filial  intelligence  is  so  slight,  that  even  its 
sign  cannot  be  detcnnined  from  the  present  mate- 
rial." 

1  Eth(;l  M.  Elderton  and  Karl  Pearson.  A  First  Study  of  the 
Influence  of  Parental  Alcoholism  on  the  Physique  and  Ability  of  the 
Offspring.     London,  1910. 


ARRESTS  OF  DEVELOPMENT.  227 

Inherited  syphilis  may  act  in  two  ways:  either  by 
giving  rise  to  a  congenital  anomaly  through  intra- 
uterine disorders  or  by  causing  the  appearance  of 
meningeal  and  cerebral  lesions  during  the  first  years 
of  life  of  which  arrest  of  development  is  the  conse- 
quence.^ 

First  Manifestations.  —  According  to  Sollier,  who 
has  made  an  extensive  study  of  these  anomalies,  the 
principal  early  manifestations  are: 

(a)  Difficulty  in  taking  the  breast;  it  seems  each 
time  that  the  act  is  a  new  one  to  the  child; 

(6)  Violent,  continued,  and  unprovoked  crying; 

(c)  Impossibility  of  fixing  the  child's  gaze; 

(d)  Lack  of  expression  in  the  physiognomy. 
Later  on,  at  the  age  when  intelligence  becomes 

manifest  in  normal  children,  the  signs  of  psychic 
insufficiency  become  more  and  more  evident.  The 
child  is  sad,  surly,  or,  on  the  contrary,  extraordi- 
narily noisy  and  turbulent.  It  does  not  speak  or  it 
may  be  able  to  say  only  a  few  words  at  an  age  when 
other  children  already  dispose  of  quite  a  vocabulary. 
More  important  than  the  language  of  transmission 
is  that  of  reception.  The  chief  characteristic  of  the 
congenital  imbecile  is  the  restricted  number  of 
words,  not  which  he  can  pronounce,  but  which  he 
can  understand. 

Physically  arrest  of  development  manifests  itself 
in  retardation  of  growth,  of  development  of  the 
hairy  system,  and  especially  of  learning  to  walk. 

^  F.  Plaut.  The  Wassermann  Sero-Diagnosis  of  Syphilis  in  its 
Application  to  Psychiatry.  (English  translation  by  Jelliffe  and  Cas- 
amajor.)     New  York,  1911. 


228  MANUAL  OF  PSYCHIATRY. 

Symptoms.  —  As  with  the  growth  of  the  child  the 
psychic  functions  become  of  greater  importance, 
their  insufficiency  becomes  more  apparent  and  mani- 
fests itself  in  the  impossibility  of  the  subject's  de- 
riving any  benefit  from  education. 

This  incapacity  is  due  to  absence  or  weakness  of 
attention  (Sollier),  so  that  the  degree  of  atrophy  of 
this  faculty  can  serve  as  a  basis  for  the  classification 
of  arrests  of  development.     Sollier  distinguishes: 

(1)  Absolute  idiocy:  complete  absence  and  impos- 
sibility of  attention; 

(2)  Simple  idiocy:  weakness  and  difficulty  of 
attention; 

(3)  Imbecility:  instability  of  attention. 

We  may  add  also  feeble-mindedness,  in  which,  as 
in  imbecility,  the  attention  is  unstable,  though  to 
a  less  marked  degree. 

Atrophy  of  attention  is,  therefore,  the  most 
important  symptom  of  arrest  of  psychic  develop- 
ment.^ 

Around  this  is  grouped  a  certain  number  of  other 
symptoms  which  I  shall  mention  briefly: 

(a)  Sluggishness  and  lack  of  variety  in  the  psychic 
processes,  entailing  insufficiency  of  judgment  and 
absence  or  rarity  of  generalized  ideas.  The  latter 
two  symptoms  are  most  striking  in  the  feeble- 
minded. 

(6)  Weakness  and  inaccuracy  of  the  memory.  An 
idiot  or  an  imbecile  is  seldom  able  to  relate  correctly 
an  event  that  he  has  witnessed.     The  details  and 

*  Sollier.     Psychologic  de  Vidioi  et  de  I'imbecile.     Paris,  F.  Alcan. 


ARRESTS  OF  DEVELOPMENT.  229 

even  the  facts  themselves  are  altered.  Quite  fre- 
quently imbeciles  relate  pseudo-reminiscences  which 
indicate  by  their  monotonous  and  childish  character 
a  very  poor  imagination. 

(c)  Moral  indifference  associated  with  morbid 
irritability  (this  symptom  is  to  be  looked  upon  as  an 
expression  of  a  disorder  of  the  moral  sense),  impul- 
sive reactions  and  extreme  suggestibility;  this  latter 
disorder,  together  with  the  weak  memory,  insuffi- 
cient judgment,  and  atrophied  moral  sense,  renders 
the  testimony  of  an  idiot  or  an  imbecile  acceptable 
only  with  extreme  caution. 

(d)  Disorders  of  language.  In  the  lowest  grade  of 
idiocy  language  is  absent.  In  simple  idiocy  and  in 
imbecility  we  usually  find: 

(1)  A  vocabulary  that  is  more  restricted  than  in 
normal  individuals  of  the  same  age  and  under  the 
same  conditions. 

(2)  Errors  of  syntax  which  are  at  times  very 
curious.  Some  idiots  make  use  of  faulty  construc- 
tion: ''Me  no  sick,"  etc.  Others  never  use  the 
pronouns,  I,  you,  he,  etc.,  referring  to  themselves 
and  to  others  by  their  proper  names.  One  imbecile, 
Elsie  B.,  used  to  say,  ''Elsie  B.  is  going  to  bed." 
The  substitution  of  a  pronoun  for  a  proper  name  is 
an  intellectual  operation  impossible  for  these  patients. 
In  the  pronunciation  we  often  notice  lisping,  stam- 
mering, and  stuttering.  Written  language,  neces- 
sitating \QYy  complex  associations,  is  still  less  de- 
veloped than  spoken  language.  Many  imbeciles  are 
unable  to  read,  and  only  few  are  able  to  write  prop- 
erly.    Writing  necessitates   delicate  movements  in 


230  MANUAL  OF  PSYCHIATRY. 

addition  to  the  difficulties  of  reading.  Language 
of  gesture  and  expression,  the  most  elementary  of  all 
forms  of  language,  is  least  affected.  Usually,  how- 
ever, it  has  not  the  same  hveliness  as  in  the  normal 
individual.  A  single  glance  suffices  to  distinguish 
the  idiot  who  does  not  speak  from  the  intelhgent 
deaf-mute. 

These  are  the  essential  and  fundamental  features 
of  idiocy  and  imbecility.  They  may  present  all 
degrees,  from  complete  idiocy,  in  which  the  mentahty 
of  the  individual  is  inferior  to  that  of  an  animal,  to 
slight  feeble-mindedness,  which  is  compatible  with 
a  normal  social  existence.  These  extremes  are  con- 
nected by  an  infinity  of  intermediate  degrees,  so 
that  no  distinct  lines  of  demarcation  can  be  drawn 
between  idiocy,  imbecility,  and  feeble-mindedness. 

All  the  mental  faculties  are  not  always  atrophied 
to  the  same  extent.  The  memory  is  sometimes  very 
good,  occasionally  even  exceptionally  so.  ^'Forbes 
Winslow  (quoted  by  Sollier)  reports  a  case  of  an 
idiot  who  could  recall  the  dates  of  death  of  all  those 
who  died  in  his  town  during  thirty-five  years,  gi\'ing 
correctly  their  names  and  ages."  Some  imbeciles 
present  relatively  remarkable  aptitudes  for  the  arts, 
especially  for  music.  They  retain  with  surprising 
facility  complicated  pieces  of  music,  and  are  able 
to  reproduce  them  passably  well  on  an  instrinnent. 
Still  they  never  accjuire  a  true  talent,  for  they  lack 
the  attention  which  is  necessary  for  the  development 
of  their  natural  aptitudes. 

Physically  all  the  anatomical  stigmata  of  degen- 
eration may  be  met  with  in  idiots  and  imbeciles. 


ARRESTS  OF  DEVELOPMENT.  231 

The  sexual  instinct  is  absent  (lowest  type  of  idiocy) 
or  abnormally  developed,  or  perverted.  Many 
idiots  and  imbeciles  are  addicted  to  masturbation, 
to  pederasty,  or  have  a  tendency  to  commit  acts  of 
rape,  exhibitionism,  sadism,  etc. 

Filthy  habits  are  frequent:  the  patients  soil  and 
wet  themselves.  Often  this  symptom  is  only  noc- 
turnal and  can  be  combated  by  constant  supervision. 

Complications.  —  These  are  somatic  and  psychic. 

The  former  arise  from  defects  of  development  or 
from  a  low  resistance  of  the  organism.  They  are, 
on  the  one  hand,  the  malformations  constituting 
the  physical  signs  of  degeneration,  and,  on  the  other 
hand,  various  infections  occurring  upon  a  basis  of 
poor  nutrition  of  the  tissues. 

Among  the  sequel®  left  behind  by  the  infections  a 
prominent  place  belongs  to  peraianent  lesions  of  the 
brain  and  cord,  which  give  rise  to  phenomena  of 
paralysis,  atrophy,  etc.  (infantile  hemiplegia,  in- 
fantile palsy,  strabismus).  These  disorders  are 
often  coincident  in  time  with  the  mental  disorders 
and  are  dependent  upon  the  same  causes. 

Epilepsy  forms  a  transition  between  the  somatic 
and  the  psychic  complications.  The  frequency  of 
infantile  convulsions  in  the  histories  of  cases  of 
arrested  development  in  itself  show^s  the  close  rela- 
tionship existing  between  epilepsy  and  arrested 
development.  Epileptic  seizures  are  frequent  in 
idiots  and  imbeciles.  The  commotion  which  the 
seizures  exercise  upon  the  psychic  functions  leads 
to  an  accentuation  of  the  mental  debility.  The  im- 
becile becomes,  in  addition,  an  epileptic  dement. 


232  MANUAL  OF  PSYCHIATRY. 

One  frequently  observes  in  the  feeble-minded 
acute  or  subacute  mental  outbreaks  which  appear  in 
various  cUnical  forms:  maniacal  excitement,  de- 
pression, sometimes  delusions  more  or  less  imper- 
fectly systematized.  Often  the  mental  disorders 
appear  as  exaggerations  of  a  constitutional  anomaly, 
essentially  a  function  of  the  subject's  make-up.  An 
individual  habitually  touchy  and  suspicious  de- 
velops persecutory  delusions,  another  habitually 
psychasthenic  suffers  an  attack  of  depression,  etc. 
Such  episodes  in  imbecility  are  incontestable  clinical 
realities,  and  nothing  is  more  justifiable  than,  for 
instance,  a  diagnosis  of  maniacal  excitement  in 
an  imbecile.  Unfortunately  it  is  very  difficult  to 
assign  for  such  episodes  a  place  in  psychiatric 
nosography.  Do  they  constitute  mental  disorders 
peculiar  to  imbecility?  Are  they  not,  on  the  con- 
trary, periodic  psychoses  to  which  the  imbecility 
merely  imparts  special  features:  mobility  of  the 
symptoms,  childish  character  of  the  delusional  con- 
ceptions? For  my  part,  I  am  rather  inclined  toward 
the  second  hypothesis.  In  fact  a  full  series  of  tran- 
sition cases  leads  from  classical  manic  depressive 
insanity  to  the  more  typical  attacks  of  imbeciles. 
Moreover,  such  attacks  in  imbeciles  present  the 
same  tendencies  toward  recovery  and  toward  re- 
currency.  It  must  be  noted,  however,  that  the 
influence  of  external  causes,  psychic  as  well  as 
physical,  in  bringing  al)out  recurrencies,  appears 
to  be  more  marked  in  imbeciles  than  in  manic  de- 
pressive persons  who  are  not  defective.  It  is  also 
to  be  noted  that  the  effect  of  suggestion  upon  the 


ARRESTS  OF  DEVELOPMENT.  233 

mental  symptoms  is  sm-ely  more  pronomiced  in  the 
psychoses  of  imbeciles  than  in  ordinary  types  of 
intermittent  psychoses,  so  that  psychic  treatment  is 
here  found  to  be  more  efficacious. 

Prognosis,  diagnosis,  treatment.  —  Arrests  of  de- 
velopment are  not  diseases,  but  infirmities;  their 
prognosis  is,  therefore,  grave.  Education  may, 
however,  exercise  a  favorable  influence  upon  some 
subjects. 

The  elements  of  diagnosis  are  to  be  found  in  the 
history  of  the  subject;  the  absence  of  any  vestige 
of  more  complete  intellectual  development  previous 
to  the  time  of  examination  must  be  established. 


CHAPTER    II. 

EPILEPSY. 

From  a  psychiatric  standpoint  epilepsy  manifests 
itself  by  'permanent  disorders  and  by  paroxysmal 
accidents.     " 

Permanent  intellectual  disorders.  —  These  impart  to 
the  epileptic  personaUty  a  peculiar  stamp  and  often 
lead  one  to  surmise  the  existence  of  the  neurosis  inde- 
pendently of  any  medical  examination.  We  shall 
consider  separately  anomalies  of  disposition  and  intel- 
lectual disorders. 

(A)  Anomalies  of  disposition.  —  These  are  always 
very  marked.     The   following  are   the   principal  ones: 

(1)  Irritability  and  variability  of  moods,  egoism, 
duplicity. 

(2)  Habitual  apathy,  sudden  impulsive  reactions, 
YJoleiit  and  at  times  terrible  fits  of  anger.  ""^ 

(3)  Lack  of  consistency  between  the  patient's  con- 
duct and  his  ideas,  more  rarely  abnormal  stubbornness 
and  tenacity:  "  Some  celebrated  men  who  are  supposed 
to  have  been  epile{)ti('s  are  more  noted  for  their  per- 
tinacity tlian  for  the  gi-(\itn(>ss  of  tlnnr  c()n('ej)tions."  •   / 

(4)  Morbid  n^ligious  fanaticism,  not  constant,  but 
frequent,  usually  ni(>rely  ostentatious,  with  more  regard 


'   I'Yjre.     Le.s  ejnlcpsirN  ct  Ics  ipilcjdiqucs,  \^.  423. 
234 


EPILEPSY.  235 

for  the  rites,  ceremonies,  and  customs,  and  without 
any  influence  upon  the  morality  of  the  patient. 

(B)  Intellectual  disorders.  —  Epileptics  are  some- 
times, but  not  often,  as  claimed  by  some  authors,  men 
of  great  intelligence.  Some  hold  prominent  places  in 
history,  in  literature,  and  in  the  arts:  such  were  Caesar, 
Napoleon,  Flaubert,  and  others.  Others,  though  m  a 
more  modest  sphere,  are  honorable  occupants  of  offices 
requiring  a  lucid  intelligence  and  a  sane  judgment. 
These  cases  are,  however,  exceptional.  Intellectual 
inferiority  almost  always  forms  a  part  of  the  clinical 
picture  of  epilepsy.  Often  it  is  congenital,  for  most 
epileptics  are  originally  feeble-minded;  in  other  cases 
it  is  acquired; "the  manifestations  of  epilepsy"-^ cerises, 
vertigo,  delirium  —  exercise  a  harmful  and  lasting 
Inlfuehce  upon  the  intelligence.  When  sufficiently 
marked,  the  intellectual  enfeeblerflent  becomes  epileptic 
dementia.  "        ' 

TTre~7Tcgree  of  dementia  depends  in  a  measure  upon 
the  number  and  severity  of  the  seizures.  \  "It  cannot 
be  doubted  that  the  stupor  produced  by  major  attacks 
is  more  marked  than  that  resulting  from  minor  ones; 
and  it  is  certain,  as  is  admitted  by  Legrand  du  Saulle, 
Voisin,  Sommer,  etc.,  that  major  seizures  occurring  at 
frequent  intervals  much  more  rapidly  lead  to  dementia 
than  do  incomplete  seizures."  ^ 

The  two  essential  features  of  epileptic  dementia  are: 
(1)  its  u'regularly  progressive  development,  with  ag- 
gravations  following  the  seizures;  (2)  its  being  to  a 
certain  extent  remittent,   the  intelle(!tual  enfeeblement 

*  P^ere.     hoc.  cit.,  p.  227. 


236  MANUAL  OF  PSYCHIATRY. 

becoming  less  marked  as  the  intervals  between  attacks 
become  longer. 

Paroxysmal  mental  disorders.  —  These  are  either  asso- 
fii^ted  with,  or  replace,  the  epileptic  seizures.  We  shall 
review  briefly  their  principal  forms. 

(A)  Sensory  and  psychic  auras.  — The  first  consist  in 
hallucinations  or  illusions;  the  second  "usually  consist 
in  a  recollection  of  either  a  pleasant  or  an  unpleasant 
character;  perhaps  a  recollection  of  some  person  or  of 
some  important  event  in  the  patient's  life."^ 

(B)  Unconsciousness  accompanying  the  convulsive  pJie- 
nomena:  though  most  frequently  complete,  it  is  some- 
times but  partial,  so  that  there  may  be: 

(a)  Vertigo,  which  is  a  dazzling  sensation  rather 
than  true  vertigo, ^  and  which  is  sometimes,  but  not 
always,  accompanied  by  falling  and  slight  convulsive 
movements.  Together  with  pallor  of  the  face  and  sub- 
sequent anaemia,  these  phenomena  constitute  a  rudi- 
mentary epileptic  seizure. 

(6)  Absence,  essentially  characterized  by  a  momentary 
suspension  of  all  psychic  operations.  The  patient  sud- 
denly becomes  immobile,  his  gaze  fixed,  his  expression 
vacant;  the  attack  having  passed,  he  resumes  his  work 
or  conversation  at  the  point  where  he  left  off.  In 
some  cases  the  patient  continues  automatically  tlirough 
the  attack  the  work  or  the  movement  in  which  he 
happens  to  be  engaged.  A  barber  mentioned  by 
Besson  thus  continued  during  his  absences  to  shave 
his  clients,  performing  his  work  just  as  skillfully  as  in  the 
normal  state. 

'  Magnan.     Lor.  cit.,  p.  6. 
'  Fere.     Loc.  cit.,  p.  V,\<o. 


V 


EPILEPSY.  237 


Exceptionally  the  absence  is  prolonged  for  hours, 
days  or  even  weeks.  Fere  rightly  includes  with  these 
absences  those  peculiar  states  of  obscuration  which  are 
known  as  epileptic  automatism,  during  which  the  patient 
may  execute  complicated  acts,  such  as  taking  a  journey 
somewhere,  stopping  in  hotels,  etc.,  without  retaining 
any  recollection  of  them  after  the  attack.  Legrande  du 
Salle  has  reported  a  curious  example  of  such  automatism : 
an  individual  who  was  at  Havre  when  his  attack  began, 
found  himself  on  the  way  to  Bombay  when  he  regained 
consciousness,  totally  ignorant  as  to  where  he  was  or 
how  he  came  there. 

These  states  resemble  states  of  somnambulism,  with 
which  they  may,  in  fact,  coexist. 

Automatism  occurs  not  only  in  connection  with 
epilepsy.  Heilbronner,  Schultze  and  others  have  shown 
that  it  is  met  with  in  most  diverse  affections :  alcoholism, 
manic  depressive  insanity,  imbecility,  and  possibly  even 
in  neurasthenia.  1 

(C)  Stupor  following  the  seizures:  This  is  a  constant 
phenomenon  which  constitutes  in  doubtful  cases  "an" 
important  element  of  diagnosis  (Samt).  It  varies  in 
duration  from  several  minutes  to  as  many  hours. 

(D)  Delirium:  This  is  the  gravest  manifestation  of 
epilepsy.  Sometimes  it  accompanies  a  convulsive 
seizure;  at  other  times  it  precedes  or  follows  it;  still 
at  other  times  it  takes  the  place  of  a  seizure. 

It  begins  with  an  accentuation  of  the  disorders  of  the 

'  Heilbronner.  Ueber  Fugues  und  fugue-dhnliche  ZusUinde. 
Jahrbiicher  f.  Psychiat.  und  Neurol.,  Vol.  XXIII.  —  Schultze. 
Ueber  krankhafien  Wandertrieb.  AUg.  Zeitsch.  f.  Psychiat.,  Vol.  LX, 
No.  6. 


238  MANUAL  OF  PSYCHIATRY. 

emotions  and  of  the  character.  The  patient  becomes 
irritable,  anxious,  and  the  delirium  establishes  itself 
very  rapidly,  often  within  several  minutes,  and  never 
taking  more  than  a  few  hours  for  its  development. 

The  fundamental  features  in  the  classical  form  are: 

(«)  Profound  clouding  of  consciousness,  with  complete 
disorientation  of  time  and  place; 

(/?)  Anxiety  which  is  sometimes  terrible;  in  some  cases 
it  gives  rise  to  violent  agitation; 

/      (7)  Numerous  hallvmnations,  combined  so  as  to  con- 
'  stitute  complete  scenes,  associated  with  delusions  of  a 
painful  nature; 

(d)  Purely  automatic  and  extraordinarily  violent  re- 
actions; the  extreme  limit  of  this  violence  is  known  as 
epileptic  furor.  In  this  condition  the  patient  often 
commits  crimes  of  revolting  brutality  bearing  the  stamp 
of  absolute  unconsciousness.  He  kills  indiscriminately 
strangers  or  his  own  children,  riddles  the  corpse  with 
thrusts  of  his  knife,  cuts  off  pieces  and  devours  them. 
In  some  cases,  which  are  rare  but  very  important  from 
the  medicolegal  point  of  view,  the  criminal  act  appears 
to  be  prompted  by  the  usual  sentiments  of  the  patient.^ 
Suicide  is  sometimes  observed; 

(s)  Amnesia,  which  is  usually  absolute,  follo\\'ing  the 
attack.  All  classical  descriptions  show  that  the  patients 
are  as  a  rule  totally  ignorant  of  the  damage  or  of  the 
crimes  which  they  have  committed.  This  rule,  however, 
has  some  excej)tions.  Tlie  patient  may  have  a  recollec^ 
tion,  most  fre(iuontly  very  vague,  of  the  acts  accom- 
plished by  him  during  the  attack.     Throe  classes  of  cases 

*  l'\'re.     Loc.  cit.,  p.  144. 


EPILEPSY.  239 

may  present  themselves:  (1)  the  subject  may  retain  a 
complete  or  a  partial  recollection  of  the  delirious  period, 
which  persists  as  an  ordinary  impression;  (2)  the 
recollection,  present  immediately  after  the  attack,  may 
be  subsequently  effaced,  and  the  patient  may  deny 
facts  which  he  previously  admitted  to  be  true; 
(3)  inversely,  the  recollection,  absent  at  the  time  when 
the  patient  comes  to,  may  appear  later  on :  the  patient 
admits  a  fact  which  he  previously  denied.  The 
recollections  of  epileptic  delirium  are  thus  similar  to 
those  of  ordinary  dreams.  We  may  forget  within  a 
few  hours  a  dream  which  we  remembered  very  clearly  at 
the  time  of  awakening  or,  more  rarely,  we  may,  on  the 
contrary,  recollect  a  dream  which  previously  seemed 
to  have  left  no  impression  whatever  upon  the  mind. 

The  following  is  an  abstract  from  the  record  of  a 
case  of  epileptic  dehrium. 

Louis  M.,  forty-two  years  old,  cab  driver.  Father  alcoholic. 
Patient  has  had  epilepsy  since  infancy.  Has  typical  epileptic 
convulsions,  though  not  frequent,  almost  exclusively  nocturnal, 
occurring  about  once  a  month.  Absences  of  long  duration:  one 
day  the  patient  found  himself  driving  his  carriage  about  eight 
miles  from  the  place  where  he  wanted  to  go,  not  knowing  how  he 
came  there. 

February  17,  1901,  towards  six  o'clock  in  the  evening,  following 
a  violent  dispute  with  a  neighbor,  the  patient  came  home  sad, 
depressed,  and  told  his  wife  that  he  would  throw  himself  into  the 
river  rather  than  live  in  such  a  disagreeable  place.  He  went  to  bed 
without  any  supper  and  fell  asleep.  About  nine  o'clock  he  stood 
up  in  his  bed,  seeming  to  be  in  great  fear  and  emitting  inarticulate 
cries,  then  ran  with  nothing  on  but  his  shirt  into  the  next  room, 
seized  a  hatchet,  and  came  back  into  the  bedroom,  where  he  began 
to  hack  away  at  everything  within  his  reach.  His  wife,  terrified, 
ran  out  and  called  for  help.  Some  of  the  neighbors  came  but  no 
one  dared  to  enter  the  bedroom.  In  the  meantime  they  could 
hear  the  strokes  of  the  hatchet  and  the  cracking  of  the  furniture. 


240  MANUAL  OF  PSYCHIATRY. 

In  a  few  minutes  the  patient  went  at  the  door  of  the  room,  kicking 
it  with  his  feet  as  though  trying  to  break  it  down,  but  making  no 
attempt  to  open  it.  Finally  three  men  climbed  into  the  room 
through  the  window  without  the  patient  hearing  them.  They 
approached  him  from  behind,  disarmed  and  overpowered  him,  and 
while  he  defended  liimself  violently  and  tried  to  bite  them,  they 
succeeded  by  the  greatest  efforts  in  getting  him  down  and  tying 
him  to  his  bed.  The  patient  struggled  violently  to  free  himself, 
but  preserved  complete  mutism  all  the  time  and  did  not  seem  to 
recognize  anyone.  His  respiration  was  panting,  skin  covered  with 
perspiration,  pupils  widely  dilated. 

Towards  five  o'clock  in  the  morning  consciousness  appeared 
to  be  returning.  The  patient  began  to  look  around  him,  noticed 
with  astonishment  the  straps  with  which  he  was  tied,  and  said  a 
few  words:  "Take  this  off  from  me.  .  .  .  What  is  the  matter 
with  all  these  peoi)le?  .  .  ."  At  about  six  o'clock  he  fell  into  a 
deep  sleep  and  woke  up  at  noon,  tired  but  lucid.  He  had  some 
recollection  of  the  beginning  of  the  attack.  He  said  he  had  had  an 
impression  that  someone  came  into  the  room  after  him  and  his 
wife;  it  was  then  that  he  uttered  the  cries  and  ran  to  get  the  hatchet. 
After  that  he  could  remember  nothing  up  to  the  time  that  he  found 
himself  tied  in  his  bed.  But  what  he  saw  even  then  he  remem- 
bered but  vaguely:  he  could  not  tell  who  were  tlie  people  whom 
he  had  seen  around  his  bed  and  said  he  believed  that  he  had  not 
recognized  them  at  the  time.  Finally  when  shown  the  damage 
which  he  had  done  (the  furniture  in  the  room  was  partly  destroyed), 
he  was  stupefied  and  refused  to  believe  that  he  was  the  cause  of  all 
that  destruction. 

An  attack  of  epileptic  delirium  lasts  from  a  few 
minutes  to  several  days.  It  may  be  reduced  to  a 
single  automatic  act.  Like  the  other  manifestations 
of  epilepsy,  it  may  be  })roduce(l  always  by  the  same 
external  influences  and  assume  the  same  form  each 
time.  This  is  of  course  far  from  being  always  the 
case. 

The  termination  of  the  delirium  is  either  sudden, 
following   a   profound    sleep,    or   gradual,   leaving   for 


EPILEPSY.  241 

several  hours  delusions  and  hallucinations  which  persist 
in  spite  of  the  return  of  lucidity. 

The  above  is  a  description  of  the  most  common,  one 
may  say  classical,  form  of  epileptic  delirium.  Another 
form  is  occasionally  met  with  in  which  ideas  of  grandeur 
occur  in  place  of  the  painful  delusions;  these  ideas  often 
assume  a  mystic  character  and  are  associated  with  a 
state  of  euphoria  which  may  reach  the  intensity  of 
ecstasy. 

The  diagnosis  is  very  easy  when  these  phenomena 
appear  in  an  old  epileptic;  it  becomes  very  difficult, 
however,  when  the  epilepsy  is  "  masked,  or  atypical  in 
its  course,"  ^ 

There  is  no  pathognomonic  sign  of  epileptic  delirium 
excepting,  perhaps,  the  stupor  which  follows  it  and  the 
importance  of  which  is  justly  insisted  upon  by  Samt 
and  Moeli.2  However,  this  stupor  may  be  so  slight  as  to 
escape  the  observation  of  those  witnessing  the  attack. 
The  previous  history  of  the  patient  may  contain  nothing 
to  aid  in  the  diagnosis  because  dehrium  sometimes 
constitutes  the  first  manifestation  of  epilepsy;  on  the 
other  hand,  epileptics  may  present  mental  disturbances 
which  have  nothing  in  common  with  their  clisease 
(alcoholic  delirium,  chronic  delusional  insanity).  Only 
upon  the  entire  symptom  complex  together  with  the  pre- 
vious history  of  the  patient  can  the  diagnosis  of  epileptic 
delirium  or  of  any  other  epileptic  manifestation  be  estab- 
lished. 

We   may   distinguish: 
I   Delirium  tremens  by  the  occupation  delirium,  by  the 

*  Magnan.     Loc.  cit.,  p.  2. 

2  Allg.  Zeitsch.  f.  Psychiat.,  1900,  Nos.  2  and  3. 


242  MANUAL  OF  PSYCHIATRY. 

intact  autopsychic  orientation,  and  by  the  stigmata  of 
chronic  alcoholism; 

States  of  transitory  confusion  encountered  in  chronic 
alcoholism,  by  absence  of  the  post-epileptic  stupor 
(MoeU); 

Delirious  attacks  of  general  paresis,  which  may  resemble 
epileptic  delirium,  by  the  patient's  previous  history  and 
especially  by  the  presence  of  the  special  physical  signs 
of  this  affection; 

Attacks  of  catatonic  excitement  by  the  relative  con- 
servation of  lucidity. 

Finally,  in  epilepsy  one  may  meet  with  attacks  of 
so-called  epileptic  mania  which  at  times  sinmlate  closely 
the  manic  type  of  manic  depressive  insanity.  However, 
in  these  attacks  flight  of  ideas  is  much  less  pronounced, 
as  a  rule,  and  the  morbid  ideas  are  much  more  firmly 
fixed  and  much  more  monotonous.^ 

Several  authors,  Krafft-Ebing  among  them,  have 
described  under  the  name  of  transitory  delirium,  or 
transitory  mania,  very  brief,  non-recurring  delirious 
attacks  which  they  consider  as  a  distinct  morbid  entity. 
The  similarity  between  these  attacks  and  those  of 
epileptic  delirium  is  such  that  most  ahenists  consider 
them  as  being  of  epileptic  origin,  at  least  in  the  great 
majority  of  cases.  This  opinion  is  entertained  notably 
by  Schwartz,^  Regis, ^  and  Vallon.'*  According  to  these 
authors  the  cases  of  transitory  delirium  which  are  not 

'  Heilbronner.     Uel>er  epileptische  Manie  veb.st  Bemerkungen  iiber 
Ideerijlucht.     Monatsch.  f.  Psychiat.  u.  Neurol.,  1902,  Nos.  3  and  4. 
'  Schwartz.     Mania  tranfijlnna.     Allg.  Zoits.  f.  Psychiat.,  1891. 
'  Rd<i;is.     Manuel  de  7nalafh'es  mcniales. 
*  Vallon.     Rapport  au  Congns  d' Angers,  1898. 


EPILEPSY.  243 

of  epileptic  origin  are  attributable  to  some  infectious 
disease,  to  alcoholism,  or  to  mental  degeneration.  In 
the  clinic  only  a  close  study  of  the  antecedents  of  a 
given  case  enables  one  to  decide  to  which  of  these 
causes  the  attack  is  due. 

The  etiology  of  epileptic  delirium  is  that  of  epilepsy 
in  general. 

Treatment  of  epilepsy.  —  We  shall  consider  separately 
the  treatment  of  epilepsy  itself  and  that  of  its  psychic 
complications. 

The  first  really  belongs  to  the  domain  of  neurology, 
and  I  shall  therefore  limit  myself  to  a  mere  statement 
of  the  principal  indications. 

(A)  Hygienic  measures; 

(B)  Medicinal  treatment. 

(A)  The  hygiene  of  an  epileptic  consists  in:  (a)  A 
diet  by  which  the  quantity  of  toxines  produced  in  the 
organism  is  reduced  to  the  minimum:  a  partial  milk 
diet  combined  with  white  meats,  vegetables,  eggs,  is 
of  great  utility.  [It  has  been  shown  by  dietetic  experi- 
ments ^  that  epileptics  have  a  special  intolerance  for 
proteid  material  in  any  form,  and  that  when  their  diet 
contains  more  proteid  than  is  actually  needed  by  the 
organism  their  convulsions  are  more  frequent  and  more 
severe  and  their  mental  condition  is  worse  than  when 
their  diet  contains  no  such  excess.  The  principal 
dietetic  indication  is,  therefore,  to  reduce  the  amount 
of  proteid  to  the  minimum  that  is  required  by  the 
organism,  replacing  the  proteid  principle,  as  far  as  it 

*  Merson.  On  the  Diet  in  Epilepsy.  The  West  Riding  Lunatic 
Asylum  Medical  Report,  1875.  —  Rosanoff.  The  Diet  in  Epilepsy. 
Journ.  of  Nerv.  and  Mental  Disease,  Dec.,  1905. 


244  MANUAL  OF  PSYCHIATRY. 

is  possible  to  do  so/  by  fats  and  carbohydrates.  Care 
must  be  taken,  however,  not  to  reduce  the  amount  of 
proteid  below  the  necessary  minimum,  for  then  a 
condition  of  proteid  starvation  is  estabUshed,  that  is  to 
say  the  patient  is  excreting  more  nitrogenous  material 
than  he  is  ingesting,  and  a  general  aggravation  of  his 
condition  inevitably  follows.]  (6)  The  suppression  of 
the  use  of  all  alcoholic  beverages,  (c)  Outdoor  life 
with  moderate  physical  and  mental  labor;  a  mild  but 
firm  moral  direction.  An  effort  should  be  made  to 
impress  it  upon  the  epileptic  that  he  is  subject  to  the 
common  laws  and  that  he  is,  like  everybody  else, 
responsible  for  his  acts. 

(B)  Medicinal  treatment.  —  Of  all  the  drugs  used  in  the 
treatment  of  epilepsy  I  shall  mention  only  the  bromides 
of  the  alkali  metals,  the  efficacy  of  which  is  incontesta- 
ble, and  opium,  which  has  gained  considerable  reputa- 
tion through  the  recent  introduction  of  a  new  method 
of  treatment. 

The  bromides  of  sodium  and  of  potassium  are  admin- 
istered either  separately  or  in  a  mixture  of  the  two 
with  bromide  of  ammonium,  which  mixture  is  some- 
times known  as  the  "  tribromide."  The  doses  vary 
according  to  the  age,  the  frequency  of  the  attacks, 
and  the  tolerance  of  the  subject.  The  maximum  that 
may  be  administered  to  an  adult  with  benefit  seems 
to  be  from  8  to  10  grams  daily.  Usually  good  results 
can  be  obtained  from  moderate  doses  —  from  3  to  6 
grams  daily. 

The  action  of  the  bromides  seems  to  be  more  pro- 

'  Herter.     Lectures  on  Clinical  Pathology,  p.  150. 


EPILEPSY.  245 

nounced  when  the  patient  is  allowed  a  "  hypochloriza- 
tion  "  diet;  that  is  to  say,  a  diet  in  which  the  amount 
of  sodium  chloride  is  reduced  as  far  as  possible  (Richet 
and  Toulouse).  1 

Flechsig  introduced  several  years  ago  a  method  of 
treatment  consisting  in  the  administration  of  increasing 
doses  of  opium  and  finally  suddenly  suppressing  the 
drug.  This  procedure  suspends  the  attacks  in  some 
cases  for  a  very  long  time.  Unfortunately  their  recur- 
rence is  always  to  be  feared. 

Treatment  of  the  mental  disorders.  —  The  first  question 
which  arises  is :  Should  an  epileptic  be  committed  ?  — 
Yes,  in  two  classes  of  cases:  (1)  if  the  seizures  are 
accompanied  by  marked  delirious  disorders;  (2)  if, 
independently  of  the  seizures,  the  patient  is  subject 
to  violent  impulses.  Epileptic  imbeciles  and  idiots 
come  under  the  same  rule. 

During  the  dehrious  attacks  the  patient  is  to  be 
constantly  watched.  Unfortunately  rest  in  bed  can 
be  instituted  only  with  great  difficulty  on  account  of 
the  profound  clouding  of  consciousness.  Prolonged 
baths  and  the  prudent  use  of  hypnotics  are  here 
especially  indicated.  Refusal  of  food  and  threatening 
collapse  are  to  be  treated  by  ordinary  methods. 

^  Capeletti  and  Ormea.  Le  regime  achlorure  dans  le  traitement 
bromure  de  I'epilepsie.    Rev.  de  Psychiat.,  Apr.,  1902. 


CHAPTER   III. 
demj<:ntia  precox. 

Under  the  name  hebephrenia,  Hecker,  inspired 
by  his  preceptor,  Kahlbaum,  described  a  psychosis 
which  develops  by  predilection  at  the  age  of  puberty 
and  which  terminates  in  a  pecuUar  state  of  intellec- 
tual enfeeblement. 

Later  Kraepelin  extended  the  views  of  Hecker 
and  added  to  this  group  catatonia,^  which  had  pre- 
viously been  considered  an  independent  affection, 
and  paranoid  dementia,  which  includes  the  majority 
of  forms  of  delusional  insanity  commonly  assigned 
to  the  vast  and  ill-defined  group  of  paranoias.  This 
fusion  resulted  in  a  new  morbid  entity:  dementia 
prcBcox. 

As  we  shall  see  later  on,  dementia  pra^cox  cannot 
be  defined  either  by  the  age  at  which  it  occurs  or  by 
the  rapidity  with  which  it  develops.  Its  specific 
element  lies  exclusively  in  the  sum  of  the  psychic 
changes,  affecting  the  emotions,  the  will,  and  asso- 
ciation of  ideas.  (Generally  these  changes  are  per- 
manent and  constitute  the  mental  deterioration  which 
is  the  most   common   outcome  of  the  disease.     In 

^  Kahlbaum.      Die  Kakilonic  odcr  dan  Spannungsirresein,  1894. 

246 


DEMENTIA  PRECOX.  247 

some  cases  these  changes  may  recede  either  tempo- 
rarily or  even  permanently. 

Dementia  prsecox  appears  in  many  forms  that 
are  difficult  to  classify.  In  Germany,  following 
Kraepelin,  three  principal  forms  are  distinguished: 
hebephrenia,  catatonia,  and  paranoid  dementia. 
Delusional  types  of  hebephrenia  resemble  paranoid 
dementia  so  closely  that  it  is  often  impossible  to  de- 
termine to  which  of  these  groups  a  given  case  is  to 
be  assigned.  It  seems  more  convenient  for  practical 
purposes  to  describe  separately  the  following  three 
forms:  simple  dementia  prsecox  without  delusions; 
dementia  prsecox  of  the  catatonic  form;  and  de- 
mentia prsecox  of  the  delusional  form. 

We  shall  study  first  the  psychic  and  somatic 
symptoms  that  are  common  to  all  forms. 

SYMPTOMS   COMMON   TO    ALL   FORMS. 

Psychic  symptoms.^  —  All  the  psychic  functions 
are  not  equally  affected.  While  orientation  and 
rnemory  are  often  preserved  or  but  little  affected, 
attention,  association  of  ideas,  the  emotions,  and  the 
reactions  areliRvays  markedly  impaired. 

Lucidity  and  orientation.  —  These  very  frequently 
remain  intact,  although  the  appearance  of  the 
patients  would  scarcely  lead  one  to  think  so.  Many 
patients  appear  to  be  ignorant  of  what  occurs  about 
them,  yet  they  will  give  rational  and  correct  replies 


^  Masselon.     Psychologic  des  dements  precoces.     These  de   Paris, 
1902. 


248  MANUAL  OF  PSYCHIATRY. 

to  questions  concerning  the  date,  their  surroundings, 
and  even  the  important  events  of  the  day.  We  shall 
return  to  this  question  in  connection  with  the  study 
of  catatonia. 

Memory.  —  Like  the  lucidity,  the  memory  is  but 
shghlly  affected,  at  least  in  the  majority  of  cases  for 
a  considerable  number  of  years.  Old  impressions 
remain  well  defined,  and  the  knowledge  acquired 
during  youth  and  childhood  is  often  astonishingly 
well  preserved.  An  old  asylum  inmate,  a  typical 
case  of  dementia  prsecox,  who  had  been  in  the  in- 
stitution for  fifteen  years,  was  still  able  to  name 
without  hesitation  and  in  their  proper  succession  all 
the  French  rulers  from  the  time  of  Clovis. 

Actual  occurrences  impress  themselves  quite  dur- 
ably upon  the  memory.  Many  patients  are  able 
to  relate  events  that  have  taken  place  since  their 
commitment,  and  can  often  even  name  the  physicians 
and  attendants  that  have  followed  each  other  on 
the  service  during  several  years. 

However,  when  the  affection  is  of  long  standing  it 
is  rare  for  the  memory  not  to  have  become  impaired 
to  some  extent.  Anterograde  amnesia  is  the  first 
to  appear;  the  power  of  fixation  becomes  dimin- 
ished. Retrograde  amnesia  appears  later  and  is 
usually  less  marked.  Little  by  little  old  impres- 
sions grow  fainter  and  may  even  become  entirely 
effaced. 

Attention.  —  This  faculty  is  always  weakened. 
Any  labor  requiring  some  degree  of  concentration 
becomes  impossible. 


DEMENTIA  PRECOX.  249 

Association  of  ideas.  —  These  are  sluggish  and 
often  occur  without  any  apparent  connection,^  giving 
rise  to  speech  which  may  reach  the  extreme  hmits 
of  incoherence.  We  have  given  a  very  typical  exam- 
ple of  such  speech.  These  incoherent  phrases  are 
uttered  quietly  and  without  the  volubility  which 
characterizes  flight  of  ideas  of  the  maniac.  On 
superficial  examination  this  phenomenon  may  create 
the  impression  of  a  profound  state  of  dementia  or 
mental  confusion,  which  in  reality  does  not  exist. 
The  patient  whose  incoherent  speech  we  have 
quoted  as  a  typical  specimen  is  perfectly  oriented 
and  possesses  good  memory. 

The  affectivity  and  the  reactions  are  greatly  im- 
paired from  the  beginning.  Indifference  consti- 
tutes an  early  and  very  prominent  symptom  of 
dementia  prsecox.  The  patient  takes  no  interest  in 
anything,  expresses  no  desires,  makes  no  complaints. 
Often  even  hunger  determines  no  reaction.  If  the 
patient  is  accidentally  forgotten  at  meal  time  he 
evinces  no  surprise  and  makes  no  protest.  As  in  all 
conditions  of  dementia,  this  disorder  of  affectivity 
is  not  a  conscious  one. 

Occasionally,  especially  at  the  onset  of  the  illness, 
this  habitual  state  of  indifference  is  interrupted  by 
explosions  of  anxiety  or  of  anger,  for  which  there  is 
often  no  apparent  cause. 

A  priori  the  emotional  indifference  of  dementia 
prsecox  would  be  expected  to  lead  to  a  reduction  of 

^  See  page  61. 


250  MANUAL  OF  PSYCHIATRY. 

the  voluntary  and  normal  reactions.  Observations 
upon  patients  show  this,  indeed,  to  be  the  case. 

On  the  other  hand,  the  automatic  reactions  are 
often  exaggerated.  They  manifest  themselves  un- 
der all  the  forms  studied  in  the  first  part  of  this 
work,  General  Psychiatry:  pathological  suggesti- 
bility, negativism,  and  impulsiveness  (stereotypy  of 
movements  and  of  attitudes,  verbigeration,  grim- 
aces, unprovoked  laughter,  etc.). 

Mental  deterioration.  —  When,  as  is  most  often  the 
case,  the  disorder  of  attention,  the  sluggish  forma- 
tion of  associations  of  ideas,  and  the  impairment  of 
affectivity  and  of  the  will,  or  in  other  words,  when 
all  the  symptoms  which  we  have  described  above 
have  become  definitely  established,  we  have  mental 
deterioration. 

The  degree  of  deterioration  is  variable.  In  some 
cases  it  apparently  affects  all  the  psychic  functions 
to  so  pronounced  a  degree  that  all  mental  activity 
seems  to  have  disappeared,  and,  from  this  point  of 
view,  the  patient  cannot  be  distinguished  from  an 
idiot  or  from  an  advanced  general  paretic.  Such 
cases  are  exceptional,  and  often  enough  the  de- 
mentia is  much  less  complete  than  it  appears  to  be 
from  a  superficial  examination,  as  is  shown  by  the 
following  case: 

Theresa  C,  formerly  a  school  teacher,  at  present  (1905)  a  patient 
at  the  Clermont  Asylum,  age  thirty-four  years.  The  disease  came 
on  at  tlie  age  of  twenty-five.  For  several  years  this  patient  has 
lived  in  a  state  of  a]){)arently  com])lete  unconsciousness,  incapable  of 
carrj'ing  out  the  simplest  commands  or  of  answering  the  most  ele- 


DEMENTIA  PRiECOX.  251 

mentary  questions.  The  facial  expression  is  silly.  The  patient 
spends  most  of  her  time  sitting  in  a  chair  or  wandering  about  the 
court-yard,  talking  incoherently,  her  utterances  showing  marked 
stereotypy.  The  word  "mystery"  keeps  recurring  in  the  manner 
of  a  Leitmotiv:  "  To  digest  the  nature  of  mystery,  Claude  of  mystery, 
Matthew  of  mystery,  Joseph  of  mystery.  It  is  a  conflagration,  it  is 
a  petticoat,  it  is  an  oblation,  resmrecHon,  when  will  you  wake  up, 
like  the  brutes.  Mystery,  of  mystery,  forty-eight  of  mystery,"  etc. 
Totally  indifferent  to  everything,  she  manifests  not  the  slightest 
emotion  when  spoken  to  about  her  family,  or  when  offered  her 
release.  She  is  filthy  in  her  habits.  And  yet,  when  a  pen  is  put  in 
her  hand  she  will  write  disconnected  words  or  fragments  of  sentences 
without  a  single  orthographical  error.  No  example  could  illustrate 
more  clearly  the  dissociation  which  characterizes  dementia  praecox 
in  which  total  ruin  of  some  faculties  is  compatible  with  perfect  con- 
servation of  knowledge  acquired  previously. 

Somatic  disorders.^  —  These  are  present  in  all 
the  three  forms  of  the  disease,  though  they  are  per- 
haps most  marked  in  the  catatonic  form. 

Motility.  —  The  disorders  of  motility  consist  in 
hemiplegias  and  monoplegias  that  are  sHght  and  of 
shlJfirHuration ;  convulsive  hysteriform  or  epilepti- 
form seizures;  and  fainting  spells.  The  contrac- 
tures often  observed  are  usually  the  consequence  of 
negativism. 

Sensibility.  —  One  must  be  guarded  against  attrib- 
uting the  absence  of  reaction  to  pricking,  which 
results  from  negativism,  to  ansethesia.  True  dis- 
orders of  sensibility  are,   however,   far  from  being 


^  Serieux  et  Masselon.     Les  troubles  physiques   chez  les  dements 
precoces.     Soc.  med.  psych.,  June,  1902. 


252  MANUAL  OF  PSYCHIATRY. 

exceptional.  They  are  often  unilateral,  as  in  hysteria. 
Other  hysterifomi  symptoms  of  the  same  order  are 
also  encountered:  tender  areas,  clavus,  globus 
hystericus,  etc. 

Tendon  reflexes.  —  Sometimes  diminished  or  abol- 
ished, much  more  frequently  exaggerated. 

Pupils.  —  Their  disorders  are  frequent  but  va- 
riable: inequality,  mydriasis,  sluggish  reaction,^  the 
phenomenon  of  Piltz,  i.e.,  contraction  of  the  pupils 
on  forcible  closure  of  the  eyehds.|  This  phenomenon 
is  analogous  to  the  following  one,  which  was  ob- 
served at  the  same  time,  independently,  by  Piltz 
and  by  Westphal:  ''If  the  patient  attempts  to  shut 
his  eye  while  his  effort  is  opposed  by  the  examiner 
who  holds  the  lids  apart  forcibly  with  the  fingers, 
a  contraction  of  the  pupil  takes  place  while  the 
eyeball  is  rolled  upward  and  outward."  ^  i 

The  pupillary  disorders  often  undergo  fluctuations 
corresponding  to  those  of  the  mental  condition.  I 
recall  a  case  of  catatonia  in  which  the  intensity  of 
the  stupor  determined,  as  it  were,  the  degree  of 
mydriasis.  As  the  stupor  disappeared  the  pupils 
reassumed  their  normal  size, 
[y  Circulatory  apparatus.  —  Vasomotor  disorders 
causing  oedema,  cyanosis  of  the  extremities,  and 
dennatographia  are  frequent.  Sometimes  the  pulse 
is  slowed. 

The  temperature  may  be  subnormal  (Kraepelin).^ 


^  Piltz.     Revue  neurologique,  1900,  No.  13. 

2  Lehrbuch  der  Psychiatrie,  7th  edition,  Vol.  II,  p.  190. 


DEMENTIA   PRECOX.  253 

Digestive  tract.  —  Indigestion,  anorexia,  and  constipa- 
tion are  often  found,  especially  during  the  acute  period. 
The  development  of  mental  enfeeblement  is  occasionally 
marked  by  boulimia. 

Urinary  apparatus.  —  Sometimes  there  is  polyuria^  at 
other  times,  on  the  contrary,  oliguria.  The  changes  in 
the  composition  of  the  urine  are  but  little  known.  A 
diminution  of  urea  and  an  increase  of  chlorides  have 
been  found.  ^ 

Secretions.  —  We  know  nothing  of  the  disorders  of  the 
secretions  excepting  that  of  sahva,  which  in  some  cases 
is  greatly  increased. 

General  nutrition.  —  Its  changes,  though  undoubtedly 
of  great  importance,  are  as  yet  but  little  known.  The 
weight  is  reduced  in  the  acute  stages,  but  rises  again 
during  the  quiet  periods.  Some  precocious  dements 
present  a  remarkable  degree  of  corpulence. 

The  physical  phenomena  which  we  have  here  men- 
tioned are  difficult  to  account  for.  They,  however, 
enable  us  to  draw  the  very  interesting  conclusion  that 
the  morbid  process  of  unknown  nature,  and  psychically 
manifested  as  dementia  praecox,  affects  not  only  the 
brain  but  the  entire  organism. 

A.      SIMPLE    DEMENTIA    PRECOX. 

In  this  form  the  symptoms  are  reduced  to  phenomena 
of  mental  deterioration  together  with  more  or  less  pro- 
nounced changes  in  disposition. 

The  onset  is  almost  always  insidious,  and  it  is  usually 
impossible  to  determine  even  approximately  its  date„ 

'  Dide  et  Chenais.  Recherches  urologiques  et  hematologiques  dans 
la  demence  precoce.     Ann.  med.  psych.,  1902. 


254  MANUAL  OF   PSYCHIATRY. 

A  subject  previously  affectionate,  active,  intelligent, 
even_brilliant,  becomes  indifferent,  indolent,  and  dis- 
tracted. He  is  weary  of  everything,  of  play  as  well  as 
oT  work.  He  ceases  to  acquire  new  ideas,  or  to  co- 
ordinate those  which  he  has  acquired  previously,  so 
that  his  general  stock  of  ideas  becomes  more  and  more 
.limited. 

Nervous  symptoms  (headache,  insomnia,  hysteriform 
disturbances)  or  constitutional  symptoms  (anorexia, 
loss  of  flesh)  are  frequent. 

In  the  mild  forms  the  disease  is  often  unrecognized. 
The  symptoms  of  intellectual  enfeeblement  pass  for 
"  negligence"  or  "  lack  of  ambition."  Such  cases  occur 
much  more  frequently  than  is  commonly  believed. 

The  following  lines  from  a  letter  addressed  by  a  prin- 
cipal of  a  school  to  the  parents  of  one  of  his  pupils  are 
very  significant  from  this  point  of  view. 

"  As  you  can  see,  the  marks  of  M.  L.  are  no  better  than  those 
for  the  preceding  term,  far  from  it.  This  pupil  pays  no  attention  to 
his  duties,  which  three-fourths  of  the  time  are  left  unfinished;  he 
no  longer  takes  the  trouble  of  learning  his  lessons.  In  the  class 
room  and  at  his  studies  he  spends  most  of  his  time  dreaming.  It  is 
evident  that  he  cares  nothing  for  his  work.  Ills  professors  no  longer 
recognize  in  him  the  former  studious  pupil.  It  seems  that  even  the 
approaching  examinations  do  not  affect  his  indifference.  When  it  is 
pointed  out  to  huu  that  he  is  likely  to  fail,  he  promis(\s  vaguely  to 
be  more  diligent,  but  one  can  see  tluit  he  has  no  firm  determination. 
The  comments  and  suggestions  in  the  letters  of  his  parents  no  longer 
have  any  effect  on  him.  .  .  Formerly  so  jolly  and  so  full  of  good 
humor,  he  has  become  quite  unsociable.  lie  docs  not  seem  to  be 
pleased  except  when  alone.  When,  by  way  of  exception,  he  joins 
his  comrades  in  conversation  or  in  play,  he  soon  leaves  them,  often 
after  quarreling  with  them  over  some  absurd  trifle.  .  .  Lately  he 
has  been  comj^laining  of  insomnia  and  headache.  We  have  had 
the  physician  see  him,  but  he  has  found  nothing  serious  and  has 
merely  prescribed  rest." 


DEMENTIA  PRiECOX.  255 

M.  L.  is  to-day  a  true  dement.  He  lives  with  his  par- 
ents and  is  at  best  able  to  do  only  simple  manual  work. 
For  a  long  time  he  showed  some  irritabihty.  Now  he 
has  become  totally  indifferent. 

B.    CATATONIA, 

Onset.  —  Prodromata  are  almost  constant;  they  pos- 
sess no  specific  features:  change  of  disposition,  inapti- 
tude for  work,  insomnia. 

Often  the  symptoms  of  melancholia  open  the  series 
of  grave  phenomena.  In  themselves  they  present  no 
pathognomonic  features,  but  consist  merely  in  a  state 
of  depression  or  psychic  pain  which  may  be  associated 
with  delusions  and  hallucinations. 

Soon  the  catatonic  phenomena  proper  appear;  they 
may  occur  also  at  the  onset  without  being  preceded 
by  the  period  of  depression  mentioned  above.  They 
depend  upon  a  disorder  of  affectivity,  indifference, 
and  a  disorder  of  the  reactions,  disappearance  of  the 
normal  will  associated  with  exaggeration  of  the  mental 
automatism.  Clinically  they  appear  in  two  principal 
forms:  catatonic  excitement  and  catatonic  stupor. 

Catatonic  excitement.  —  Sometimes,  especially  at  the 
beginning,  it  simulates  an  attack  of  confusional  insanity 
or  of  mania;  disordered  movements,  incoherent  speech, 
impulsive  reactions.  Soon,  however,  the  nature  of 
the  symptoms  becomes  more  definite  and  the  peculiar 
characteristics  of  catatonic  excitement  ai)pear.  Its 
principal  features  are  four  in  number: 

(1)  Catatonic  excitement  is  free  from  any  emotion; 

(2)  It  is  not  influenced  by  external  impressions; 


256  MANUAL  OF  PSYCHIATRY. 

(3)  It  is  not,  at  least  in  the  majority  of  cases,  gov- 
erned by  definite  delusions; 

(4)  It  is  monotonous  (stereotyped  movements,  ver- 
bigeration). 

In  other  words,  the  reactions  in  catatonic  excitement 
attain  the  extreme  limits  of  automatism. 

The  spells  of  excitement  occur  without  cause,  in  an 
impulsive  and  unexpected  manner.  The  patient  per- 
forms most  singular  and  at  times  most  dangerous  acts 
without  being  able  to  furnish  any  explanation  for  his 
conduct  even  when  the  attack  has  passed  and  has  left 
in  his  mind  a  clear  recollection  of  all  that  he  did.  A 
catatonic,  perfectly  composed  an  instant  before,  leaves 
his  bed,  seizes  a  glass  and  throws  it  violently  at  the 
head  of  his  neighbor.  Another  breaks  to  pieces  a  ther- 
mometer imprudently  left  in  his  possession.  A  third 
calls  loudly  for  a  drink  of  water  while  holding  in  his 
hand  a  glass  filled  to  the  brim.  Some  display  for  weeks 
or  months  suicidal  tendencies  without  there  being  any 
depressive  ideas  to  account  for  them. 

The  movements,  attitudes,  and  conversation  present 
stereotypy  and  verbigeration.  Often  the  patients  as- 
sume an  affected  or  dramatic  air.  Their  gestures, 
manners,  and  fantastic  dross  frequently  survive  the 
period  of  excitement  and  persist  through  the  quiet 
j)eriods  and  the  terminal  dementia.  Some  patients 
will  hop  on  one  foot  for  months  instead  of  walking; 
others  will  invaria]:)ly  respond  to  all  questions  by  the 
same  phrase;  still  others  will  not  eat  their  food  without 
first  mixing  it  up  into  a  disgusting  mess;  others,  again, 
will  walk  back  and  forth  on  a  short  path  all  day  long, 
taking  alternately  a  certain  number  of  steps   forward 


DEMENTIA   PRECOX.  257 

and  the  same  number  backward.  Such  examples  could 
be  multiplied  indefinitely.  Most  frequently  these  pecu- 
liarities in  the  conduct  of  the  patient  are  purely  auto- 
matic and  remain  inexplicable.  They  are  usually 
not  dependent  upon  delusions.  Their  origin  lies  in  a 
perversion  of  the  reactions,  and  not  in  any  disorder  of 
ideation  or  of  perception.  Although  delusions  and 
hallucinations  are  not  invariably  absent  in  catatonia, 
as  is  insisted  upon  by  Tscliisch,  they  are,  however,  too 
rare  to  explain  the  anomalies  of  the  reactions,  which 
are  constant. 

Catatonic  stupor.  —  This  may  follow  a  period  of  depres- 
sion or  one  of  catatonic  excitement,  or  it  may  be  primary, 
constituting  the  onset  of  the  disease. 

In  its  true  sense  the  term  "  stupor  "  implies  the  exist- 
ence of  a  profound  disorder  of  consciousness.  In  this 
connection,  however,  the  word  is  used  in  a  different 
sense.  As  a  matter  of  fact  lucidity  is  but  slightly  if 
at  all  impaired"  in  the  catatonic.  Impressions  of  the 
external  world  are  perceived  almost  normally.  Very 
frequently  the  patient,  though  seemingly  unconscious 
of  his  surroundings,  relates,  after  the  stuporous  attack 
has  passed,  with  surprising  precision  the  facts  which 
would  seem  to  have  totally  escaped  his  observa- 
tion. 

In  spite  of  appearances  catatonic  stupor^  is  there- 
fore not  the  result  of  an  intellectual  disorder  proper, 
but,  like  catatonic  excitement,  of  a  disorder  of  the 
will. 

Automatism  of  the  reactions  is  met  with  in  three 

'  Tschisch.  Die  Katatonie.  A  Russian  work  abstracted  in 
Allgem.  Zeitschr.  fiir  Psychiatric,  1900. 


258  MANUAL  OF  PSYCHIATRY. 

forms,  which  we  have  already  mentioned:  negativism, 
stereotypy,  and  pathological  suggestibility. 

Negativism  is  manifested  in  simple  acts,  such  as 
movements  of  a  limb,  as  well  as  in  complex  acts,  such 
as  eating,  dressing,  etc.  The  patient  fails  to  react  to 
stimuli  either  from  the  external  world  or  from  his  own 
organism.  1  An  order  given  is  not  executed.  Pricking, 
even  when  deep,  produces  no  movement,  not  because  it 
is  not  felt,  but  because  voluntary  reaction  is  annihilated. 
Hunger  produces  no  reaction.  The  urine  accumulates 
in  the  bladder,  saliva  in  the  mouth,  faecal  matter  in 
the  rectum  \nthout  there  being  any  true  paralysis. 

Two  particularly  interesting  forms  of  negativism  are 
mutism  and  refusal  of  food.  Either  symptom  may 
persist  for  a  long  time  without  interruption  and  each 
may  present  very  diverse  characteristics. 

Stereotypy  is  seen  in  the  attitudes  and  in  the  physiog- 
nomy. 

Certain  patients  assume  very  singular  positions: 
extreme  flexion  of  the  limbs,  a  squatting  position,  the 
elbows  upon  the  knees,  the  head  drawn  back,  etc. 

The  physiognomy  of  the  patient  is  often  distorted 
by  grimaces.  The  lips  are  contorted  in  a  kind  of 
grin,  or  protruded,  as  though  the  patient  were  making 
faces.  The  eyes  may  be  closed  tightly.  These  phe- 
nomena may  persist  for  months  or  years.  Almost 
always,  at  least  in  the  beginning,  they  disappear„during 
sleep. 

Pathological  suggestibility  often  alternates  with  nega- 
tivism.    Certain  catatonics  retain  any  attitude  in  which 

'  Stoddart.  Anesthesia  in  the  Insane.  The  Journal  of  Mental 
Science,  Oct.,  1899. 


DEMENTIA  PRiECOX.  259 

they  may  be  placed,  even  the  most  uncomfortable 
(cataleptoid  attitudes).  Incapable  of  making  their 
toilet  they  submissively  allow  themselves  to  be  washed, 
combed,  and  dressed.  Many  become  filthy  and  soil 
and  wet  themselves  unless  taken  to  the  toilet  at  regular 
intervals.  Sometimes  a  single  impulse  suffices  to  start 
the  subject  and  make  him  accomplish  in  a  sort  of 
mechanical  manner  some  habitual  act  or  even  series 
of  acts:  once  seated  at  the  table  with  his  plate  filled 
in  front  of  him,  he  may  eat  hke  any  normal  person. 

Echolalia  and  echopraxia,  —  phenomena  which  are  also 
dependent  upon  suggestibility,  —  are  not  infrequent. 

Like  catatonic  excitement,  catatonic  stupor  is  essen- 
tially free  from  emotion. 

The  following  case  is  a  good  illustration  of  catatonic 
excitement  and  of  catatonic  stupor. 

Adrienne  P.,  patient  at  the  St.  Anne  Asylum,  corset  maker, 
twenty-five  years  old  at  the  onset  of  her  illness.  —  Heredity:  paternal 
grandfather  died  at  the  age  of  sixty  years  of  senile  dementia;  father 
is  an  alcoholic,  has  been  committed  twice;  paternal  aunt  committed 
suicide.  —  The  patient  began  to  walk  and  speak  very  late  in  child- 
hood; menstruation  appeared  at  the  age  of  seventeen,  has  been  regu- 
lar but  painful.  She  has  shown  no  abnormality  in  intelUgence  or 
in  disposition.  —  At  nineteen,  pleurisy.  At  twenty-four,  during  a 
sojourn  at  London,  a  severe  attack  of  scarlet  fever  with  pronounced 
albuminuria ;  patient  was  sick  three  and  a  half  months ;  convalescence 
lasted  two  months.  Since  then  (fall  of  1897),  the  relatives  noticed  a 
change  in  the  mental  condition  of  the  patient  from  the  letters  which 
she  wrote  home.  On  her  return  to  France  Adrienne  was  gloomy, 
irritable,  apathetic.  She  refused  to  work  and  often  even  to  rise  in 
the  morning.  Complete  loss  of  appetite,  headache.  Much  worried 
about  her  health,  she  consulted  several  physicians  but  with  no 
appreciable  result. 

On  October  20,  1898,  acute  symptoms  set  in  in  the  form  of  dis- 
orders of  perception.  The  people  are  "  droll,"  the  dishes  served  in 
the  restaurant  arc  "  droll,"  hfe  is  "  droll  "  and  "  absurd."     At  the 


260  MANUAL  OF  PSYCHIATRY. 

same  time  hallucinations  of  vision  apjseared:  the  patient  saw 
men  following  her,  also  ghosts  and  stars.  On  October  26  she 
started  out  to  go  to  her  sister  who  lived  in  the  suburbs  of  Paris; 
failing  to  find  her  she  walked  at  random  and  wandered  around 
the  country  for  two  days  and  two  nights.  She  was  found  walking 
along  a  railroad  track,  hor  huir  undone,  her  clothes  in  disorder;  they 
arrested  her  and  took  her  to  the  Corbcil  Hospital  where  she  remained 
eight  days  in  complete  mutism.  On  her  return  to  her  mother  her 
mutism  disapjwared,  but  she  gave  no  explanation  of  what  she  did, 
telling  simply  that  she  had  seen  things  which  friglitened  her:  terrible 
men  and  animals.  For  some  time  she  remained  relatively  quiet,  but 
depressed  and  intractable.  She  refused  to  see  a  physician,  though 
her  motlier  begged  her  to  do  so.  On  the  night  of  November  24 
she  suddenly  became  greatly  excited,  cried,  gesticulated,  and 
uttered  incoherent  remarks  some  of  wliich  were  suggestive  of 
hallucinations:  she  spoke  of  men  following  her  and  of  saints  whom 
she  saw.     She  tried  to  throw  herself  out  of  the  window. 

On  being  brought  to  the  clinic  on  November  28  she  was  in  almost 
complete  mutism.  To  ail  questions  put  to  her  she  responded  by 
outlandish  gestures  and  grimaces  bearing  no  reference  to  the  ques- 
tions. On  being  asked  to  write  she  tore  the  piece  of  paper  which 
was  offered  her. 

On  December  1,  at  the  occasion  of  a  visit  from  her  mother, 
Adrienne  came  out  of  her  mutism  but  her  remarks  were  incoherent. 
"  She  cannot  see,  she  can  see  very  clearly.  ...  It  is  Alfred,  it 
is  Martin  speaking  to  her.  .  .  .  They  are  not  saying  anything." 
It  was  very  difficult  to  tell  whetlier  she  really  had  hallucinations. 

Towards  the  evening  she  became  totally  estranged  from  the 
external  world.     She  no  longer  responded  to  any  question. 

Spells  of  excitement  and  of  stupor  have  since  tlien  followed  each 
other  witliout  any  regularity,  presenting  respectively  the  character- 
istic features  of  catatonic  cxcit(>mcnt  and  of  catatonic  stupor. 

The  excitement  is  purely  automatic.  The  same  movements  are 
constantly  repeatetl  monotonously  and  aimlessly.  For  liours  at 
a  time  the  patient  goes  through  peculiar  and  incomprehensible 
gestures,  striking  the  floor  alternately  with  the  riglit  foot  and  with 
the  left  foot,  and  extending  her  arms  and  clenching  her  fists  in 
a  threatening  manner  but  never  striking  any  one.  She  stands  up 
in  her  bed  in  a  dramatic  attitude,  draped  with  the  blanket,  and 
frozen,  so  to  speak,  in  that  position,  uncomfortable  as  it  is. 
In  her  attacks  of  excitement  she  displays  considerable  physical 
strength.     On  May  25,  1900,  she  made  a  steady,  persistent  attempt 


DEMENTIA  PRiECOX  261 

to  leave  her  bed  and  get  out  of  the  dormitory;  her  eyes  were  shut, 
her  expression  apathetic,  and  she  uttered  not  a  word  or  a  cry. 
Several  nurses  held  her  back  with  difficulty. 

Her  utterances  show  either  incoherence  or  verbigeration.  On 
January  15,  1900,  she  stood  up  in  her  bed  and  sang  for  several 
hours:  "  The  baker's  wife  has  money,"  etc.  On  May  23,  of  the  same 
year,  she  kept  repeating  during  several  hours  without  interruption 
"  Hail   Mary,"  etc. 

She  sliows  marked  negativism.  Wlien  spoken  to  she  will  give  no 
response,  showing  absolute  mutism;  she  resists  systematically  all 
attempts  at  passive  movement:  to  open  her  mouth,  to  flex  an  ex- 
tended limb,  or  vice  versa.  The  command  to  open  her  eyes  results 
immediately  in  a  spasm  of  the  orbicularis  muscle.  Refusal  of  food 
is  at  times  complete,  and  then  the  patient  has  to  be  tube-fed;  at 
other  times  it  is  partial,  the  patient  taking  only  liquid  food  which  is 
poured  into  her  mouth  by  means  of  a  feeding  cup  and  which  she  then 
swallows  readily.  On  November  4,  without  any  apparent  reason, 
she  ate  spontaneously  a  piece  of  bread  which  she  took  from  the  table. 
For  two  days  she  thus  took  bread,  cheese,  and  chocolate,  but  per- 
sistently refused  everything  else.  Later  she  relapsed  into  her  former 
state  and  now  takes  none  but  liquid  food  which  has  to  be  poured 
into  her  mouth.  Her  sensibility  appears  to  be  normal,  but  all 
reaction  is  annihilated.  Painful  pricking  with  a  pin  causes  slight 
trembling,  but  no  cry,  nor  any  movement  of  defense. 

In  the  stuporous  phases  the  patient  lies  in  her  bed,  completely 
immobile.  Generally  this  immobility  is  dominated  by  negativism 
which  is  manifested  by  the  same  traits  as  those  observed  in  her 
excited  phases.  On  several  occasions,  however,  she  has  shown 
very  marked  suggestibility.  Thus  once  she  submitted  readily, 
though  passively,  to  being  dressed  and  taken  to  the  office  of  the 
ward  physician.  When  standing  she  remains  motionless,  yet  she 
will  walk  mechanically  as  soon  as  she  is  pushed.  When  invited  to 
sit  down,  the  patient  slightly  flexes  her  legs  and  makes  a  movement 
as  though  starting  to  sit  down,  showing  that  the  command  is  under- 
stood; yet  she  will  go  no  further,  but  remains  standing.  When 
taken  by  the  shoulder  and  slightly  pushed  she  sits  down  without 
trouble.  Her  limbs  are  flaccid  and  present  no  resistance  to  any 
passive' movement.  Negativism  persists  only  in  the  muscles  of  the 
mouth  and  eye-Hds,  which  remain  closed  and  resist  being  opened. 
Cataleptoid  attitudes  are  rare.  One  was,  however,  observed  on 
October  30,  1900.  The  right  arm  was  held  for  ten  minutes  in  com- 
plete extension.     On  the  following  day  this  symptom  disappeared. 


262  MANUAL  OF  PSYCHIATRY. 

The  patient  soils  and  wets  her  bed  frequently,  though  not  con- 
stantly, both  during  the  periods  of  excitement  and  during  those  of 
stupor. 

The  general  nutrition  is  profoundly  affected;  the  skin  is  discolored, 
the  hair  is  falling  out,  and  there  is  considerable  emaciation:  from 
December,  1898,  until  May,  1899,  the  patient's  weight  fell  from  94 
pounds  to  77  pounds. 

In  March,  1901,  tlie  patient,  considered  as  being  completely 
incurable,  was  transferred  to  another  asylum. 

Save  in  the  rare  cases  in  which  the  disease  terminates 
in  recovery,  the  catatonic  comes  out  of  his  spell  of 
excitement  or  of  stupor  with  more  or  less  intellectual 
enfeeblement. 

Often  some  of  the  catatonic  phenomena  persist,  thus 
disclosing  the  origin  of  the  dementia;  stereotyped  atti- 
tudes, mannerism's,  verbigeration,  etc. 

The  following  case  illustrates  this  point. 

Suzanne  N.,  patient  at  the  Clermont  Asylum,  at  present  (1904) 
fifty-eight  years  old.  The  disease  came  on  in  1894,  when  the 
patient  was  forty-eight  years  old.  The  clinical  record  in  this  case 
shows  an  affection  developing  by  alternating  attacks  of  excite- 
ment and  depression,  with  occasional  mutism  and  refusal  of  food. 
For  the  past  several  years  the  patient  has  been  living  apparently 
estranged  from  all  that  surrounds  her.  She  never  speaks  to  tlie 
physician,  to  tlie  nurses,  or  to  any  of  the  other  patients.  She 
answers  no  questions,  carries  out  no  command.  Negativism  is 
very  marked.  Any  attempt  to  open  her  mouth,  shake  hands 
with  her,  etc.,  meets  with  absolute  resistance.  Tlie  patient's 
gestures,  actions,  and  utterances  present  all  the  features  of  stereo- 
typy. For  hours  she  keeps  repeating  certain  movements,  which 
would  surely  very  soon  tire  out  a  normal  ])erson,  and  which  consist 
in  shaking  both  hands  up  and  down  a  good  deal  like  little  children 
do  in  imitation  of  marionettes.  When  free  she  starts  immediately 
for  the  nearest  door  wliich  she  tries  to  open,  and,  when  she  suc- 
ceeds in  doing  so,  continues  to  walk  straight  ahead  without  any 
aim.  Yet  if  she  is  tied  in  kcr  chair,  even  though  it  be  only  with 
nothing  stronger  than  a  woolen  thread,  she  will  not  budge.  When 
the  door  of  the  ward  is  shut  siie  is  completely  mute,  —  but  the 


DEMENTIA  PRECOX.  263 

instant  the  door  is  opened,  she  begins  mechanically,  like  a  spring 
that  is  suddenly  released,  to  repeat  in  a  monotone:  "Eucharist, 
penance,  extreme  unction,"  or  "Jesus  Christ,  Holy  Sacrament," 
or  she  recites  from  beginning  to  end:  "I  believe  in  God,"  etc. 
This  is  kept  up  as  long  as  the  door  remains  open,  but  ceases  aa 
soon  as  it  is  shut. 

She  is  very  untidy  in  her  habits,  spilling  her  food  upon  her 
dress  and  often  urinating  in  her  bed  or  in  her  clothes. 

In  spite  of  the  complete  indifference  which  she  shows,  the 
patient  is  perfectly  lucid.  Nothing  that  occurs  about  her  escapes 
her  observation.  During  the  visits  of  her  relatives  her  mutism 
disappears  as  if  by  magic.  She  converses  readily  and  tells  all  the 
gossip  of  the  institution:  they  had  a  feast  on  mid-Lent,  Mrs.  X. 
got  a  new  dress,  etc. 

The  disease  often  develops  in  repeated  acute  attacks, 
each,  whatever  be  its  form,  leaving  behind  it  a  more 
advanced  degree  of  mental  deterioration.  Occasionally 
attacks  of  excitement  and  stupor  alternate  with  each 
other  with  a  certain  regularity,  simulating  circular 
insanity. 

C.  DEMENTIA  PRECOX  OF  THE  DELUSIONAL  FORM. 

The  prodromata  consist,  as  in  most  psychoses,  in 
change  of  disposition,  insomnia,  and  impairment  of 
general  health. 

Schematically  we  may  distinguish  in  the  delusional 
form  of  dementia  praecox  two  extreme  types  which  are 
connected  by  a  great  many  intermediate  types:  (1)  The 
incoherent  type;  (2)  The  systematized  type. 

(i)  Dementia  praecox  with  incoherent  delusions.  —  As 
this  name  indicates,  the  delusions  and  the  numerous 
hallucinations  which  usually  accompany  them  follow 
each  other  without  any  connection  or  governing  idea, 
and  are  accepted  by  the  patient  as  they  appear,  without 


264  MANUAL  OF  PSYCHIATRY. 

any  attempt  on  his  part  to  find  an  explanation  or  an 
interpretation  for  them. 

The  general  character  of  the  delusions  may  be  of 
three  varieties: 

(a)  Dej/ressive  variety:  Melancholy  delusions  associated 
with  more  or  less  marked  depression  and  hallucinations 
of  a  painful  ilature.  Often  ideas  of  persecution  are  added 
to  the  melancholy  ideas,  and  occasionally  they  even 
predominate.  It  is  not  rare  to  encounter,  especially 
at  the  beginning  of  the  disease,  attacks  of  very  pro- 
nounced anxiety,  suicidal  ideas  and  attempts,  or  violent 
tendencies. 

(6)  Maniacal  variety:  Excitement,  irritability,  mor- 
bid euphoria,  ideas  of  grandeur  occasionally  associated 
with  ideas  of  persecution,  numerous  hallucinations, 
erotic  tendencies,  and  sometimes  a  certain  degree  of 
confusion, 

(c)  Mixed  variety:  The  two  preceding  varieties  are 
seldom  met  with  in  a  state  of  purity.  They  are  almost 
always  combined  with  each  other  in  one  of  two  different 
ways: 

(1)  States  of  depression  and  those  of  excitement 
alternate  without  any  order,  and  mutually  replace  each 
other  every  instant;  in  other  words,  the  delusional  state 
is  polymorphous. 

(2)  The  disease  develops  in  three  stages: 

I.  Depression  with  melancholy  delusions; 

II.  Excitement  with  expansive  delusions; 
in.  Dementia. 

Sometimes,  as  in  catatonia,  the  disease  assumes  a 
circular  type.  There  are  recurrent  attacks,  each  con- 
sisting of  a  phase  of  depression  and  one  of  excitement 


DEMENTIA  PRECOX.  265 

and  leaving  behind  each  time  a  more  pronounced  state 
of  dementia. 

(2)  Dementia  praecox  with  systematized  delusions.  — 

This  is  the  type  to  which  the  term  paranoid  dementia  is 
most  applicable.  The  systematization  of  the  delusions 
is  not  equally  accurate  in  all  cases.  Sometimes  it  is 
quite  perfect,  'SO  that  the  disease  resembles  chronic 
delusional  insanity.  In  other  cases  the  systematization 
is,  on  the  contrary,  so  imperfect  that  one  hesitates  to 
classify  the  case  among  the  precocious  dements  with 
systematized  delusions.  We  have  already  seen  that 
there  exists  between  the  two  delusional  forms  of  dementia 
praecox  an  infinity  of  intermediate  forms. 

Lucidity  is  preserved  except  during  the  transitory 
acute  paroxysms,  which  are  of  frequent  occurrence. 

Hallucinations  are  frequent  and  affect  all  the  senses. 

Dementia  supervenes  after  a  variable  period  of 
time,  which  is  in  some  cases  very  long.  As  it  progresses 
the  number  of  delusions  becomes  more  and  more  limited, 
the  hallucinations  diminish  in  frequency  and  in  intensity, 
and  the  reactions  become  weaker  and  weaker.  Often 
the  system  of  delusions  is  reduced  to  one  or  tw^o  morbid 
ideas,  crystallized,  so  to  speak,  and  constituting  a 
"paranoic  residue"  which  remains  as  the  last  vestige 
of  the  delusional  state  ori^nally  characterizing  the 
affection.  Neolo^sms  are  frequent  in  the  period  of 
dementia. 

The  systematized  type  of  delusional  dementia  praecox 
is  met  with  in  three  principal  varieties: 

(a)  Persecutory  variety; 

(6)  Melancholic  variety; 

(c)  Megalomaniacal  variety. 


266  MANUAL  OF  PSYCHIATRY. 

(o)  Persecutory  variety.  —  The  delusions  may  either 
appear  rapidly ,  after  a  brief  period  of  prodromata,  or,  on 
the  contrary,  they  may  develop  slowly,  accompanied  at 
first  by  false  interpretations  and  only  later  by  hallucina- 
tions, as  in  chronic  delusional  insanity,  which  we  shall 
discuss  farther  on. 

The  jjsycho-sensory  disorders,  hallucinations  and  illu- 
sions, are  constant,  of  an  unpleasant  nature,  and  may 
afT^ct  any  of  the  senses.  Hallucinations  of  the  genital 
sense  are  frequent. 

The  reactions  consist  in  defensive  acts;  these  reactions 
become  gradually  weaker  as  the  dementia  becomes 
established. 

The  dementia  is  often  announced  by  disaggregation  of 
the  personality,  with  such  symptoms  as  autochthonous 
ideas,  motor  hallucinations,  stealing  and  echo  of  the 
thoughts,  etc.  The  time  of  its  appearance  is  quite 
variable.  Multiplicity  of  hallucinations  usually  indicates 
a  grave  prognosis  and  points  to  a  rapid  evolution  towards 
intellectual  enfeeblement. 

It  is  not  rare  to  note  some  degree  of  excitement 
appearing  in  paroxysmal  attacks. 

(h)  Melancholic  variety.  —  At  the  onset  the  melan- 
choly ideas  present  no  peculiarity.  There  are  ideas  of 
culpability,  humility,  ruin,  etc.,  as  in  the  melancholia 
of  involution  or  in  manic  depressive  insanity.  Later 
they  group  tliemsehTS  so  as  to  form  a  delusional 
system  which  {persists  until  the  appearance  of  dementia. 

All  varieties  of  psycho-sensory  disturbances  are  met 
witli.  The  most  important  are  motor  hallucinations, 
whicli  arc  of  <iuit(^  fro<|U(>nt  occurrence  and  indicate 
already  advanced  ])sycliic  disaggregation. 


DEMENTIA  PRiECOX.  267 

Mystic  ideas,  ideas  of  possession,  hypochondriacal 
ideas,  and  ideas  of  negation  are  frequent.  Occasionally 
the  symptoms  present  themselves  in  the  form  of  the 
syndrome  of  Cotard. 

Attacks  of  anxiety,  common  in  the  beginning,  as  they 
are  in  all  psychoses  in  which  the  depressed  state  pre- 
dominates, become  less  and  less  frequent  as  the  peculiar 
indifference  of  dementia  pra^cox  establishes  itself,  and 
the  most  frightful  delusions  often  exist  without  any 
emotional  reaction. 

As  in  the  preceding  form,  the  intellectual  enfeeblement 
often  takes  a  long  time  to  develop. 

(c)  Megalomaniacal  variety.  —  The  ideas  of  grandeur 
may  either  be  primary^  or  they  may  follow  a  very 
brief  period  of  ideas  of  persecution.  They  assume  the 
most  varied  forms.  The  patients  claim  to  be  owners 
of  immense  fortunes,  to  be  of  illustrious  descent,  to 
possess  remarkable  talents,  etc. 

The  hallucinations,  which  are  less  numerous  and 
less  constant  in  this  than  in  the  two  preceding  vari- 
eties, are  always  of  an  agreeable  nature.  The  develop- 
ment of  dementia  is  usually  rapid. 

(d)  Mixed  varieties.  —  The  three  preceding  varieties 
may  combine  with  each  other  so  as  to  form  four  principal 
mixed  types: 

Type  I:  Period  of  melancholia;  period  of  persecutory 
ideas;  period  of  dementia. 

Type  II:  Period  of  melancholia;  period  of  perse- 
cutory ideas;  period  of  grandiose  ideas;  period  of 
dementia. 

Type  III:  Period  of  melancholia,;  period  of  grandiose 
ideas;  period  of  dementia. 


268  MANUAL  OF  PSYCHIATRY. 

Type  IV:  Period  of  persecutory  ideas;  period  of 
grandiose  ideas;  period  of  dementia. 

Tiie  different  periods  almost  always  overlap;  melan- 
choly ideas  and  ideas  of  persecution,  for  instance,  often 
coexist;  and  the  same  is  true  of  ideas  of  grandeur  and 
ideas  of  persecution. 

I  regret  that  the  space  at  my  disposal  is  so  limited 
as  to  preclude  my  citing  cases  illustrative  of  all  the 
different  varieties  of  paranoid  dementia.  I  shall  have 
to  limit  myself  to  the  citation  of  one  case*  which  seems 
to  have  reached  its  complete  development  and  which 
will  give  the  reader  a  good  idea  of  paranoid  dementia 
with  imperfectly  systematized  delusions  and  with 
mental  deterioration. 

Louise  S.,  fifty  years  of  age,  occupation  day  worker.  The 
disease  came  on  in  1882.  Tlie  record  of  examination  at  that  time 
shows  a  state  of  depression  with  ideas  of  persecution  and  numerous 
hallucinations.  Toward  1886  systematized  delusions  of  persecu- 
tion had  developed,  also  combined  with  hallucinations.  From 
1890  to  1892  the  patient  had  spells  of  extreme  excitement,  caused, 
it  seems,  by  auditory  hallucinations;  in  her  excited  spells  she 
made  many  violent  assaults  on  those  aliout  her.  Since  1894  the 
delusions  lost  their  systematization. 

At  present  the  patient  presents  a  rather  incoherent  delusional 
state,  consisting  of  ideas  of  persecution,  ideas  of  grandeur,  hallu- 
cinations of  hearing  and  of  vision,  and  characterized  by  formation 
of  numerous  neclogisins. 

The  patient's  persecutors  are  two  in  number:  a  man  and  a 
woman.  They  sleep  in  the  asylum  at  night.  But  they  go  out 
every  morning  and  the  patient  sees  them  wandering  about  in  the 
vicinity  of  the  asylum  (visual  hallucinations).  She  sees  them 
"in  a  by-place,  like  the  trees  in  the  distance."  All  that  she 
knows  about  their  dress  is  that  the  woman  wears  a  black  scarf 
with  tricolored  stripes  at  the  ends:  green  ami  two  shades  of 
red.  Their  name  is  "Tantan."  As  they  go  by  they  shout: 
"Thore  are  the  Tantans!  There  are  the  Tantans!"  Their  re- 
marks contain  many  neologisms.     They  complain  of  being  "  knai- 


DEMENTIA  PR.ECOX.  269 

fied"  (tied  together)  by  a  cord  which  they  call  "credamina". 
When  they  see  the  peasants  at  work  they  say:  "We  shall  'char- 
lott'  (stroll  around),  that  will  be  better."  They  pour  out  impre- 
cations and  threats  against  the  "asilette"  (sanitarium):  "Nasty 
asilette!  .  .  .  We  shall  'founder'  the  asilette!  .  .  .  We  shall 
open  fire  upon  the  asilette!"  They  try  to  poison  the  food  of  the 
patients,  and  this  spoils  the  taste  of  the  food  and  causes  symptoms 
of  poisoning.  They  call  the  patient  "cracked"  and  threaten  to 
kill  her.  But  she  is  not  afraid  of  them,  as  she  has  authority  over 
them,  provided  the  physicians  will  give  her  the  power.  On  the 
thirteenth  of  last  February  she  made  them  pay  502  francs  which 
they  owed  her  for  washing.  They  are  very  deeply  in  debt;  they 
owe  especially  a  great  deal  of  money  to  the  town  of  Clermont 
and  they  are  condemned  to  wander  until  they  have  paid  off  all 
their  debts. 

The  patient's  ideas  of  grandeur  are  much  more  incoherent  than 
those  of  persecution.  The  patient  has  two  existences.  The  dura- 
tion of  the  first  — •  which  preceded  her  birth  —  is  reckoned  in 
centuries.  The  second,  which  is  her  "minority,"  is  reckoned  as 
forty-nine  years  (her  real  age).  She  has  assumed  a  fictitious 
name:  Mrs.  Schlem,  nee  Madeleine  Vean  Marcille.  Each  human 
being  coming  from  the  hands  of  God  should,  according  to  her,  bear 
a  "number  of  creation."  Hers  is  2511.  Born  in  Alsace  (which  is 
correct),  she  was  brought  up  in  the  land  of  "Frantz,"  a  country 
like  France,  only  "more  ancient  and  more  serious,"  governed  at 
once  "by  a  republic,  a  king,  and  an  emperor."  She  spent  part  of 
her  life  in  the  "Helvandese"  republic.  She  made  her  living  there 
by  manufacturing  desserts.  Since  then  she  became  the  successor 
of  Her  Majesty  "  Angerguma,"  the  queen  of  the  "Sgoths,"  a  people 
living  between  Switzerland  S  and  Switzerland  C.  She  has  59 
million  francs  which  she  earned  by  working  as  a  nurse  for  children 
and  later  as  a  portress.  Her  wages  were  3  francs  per  day.  She 
was  nurse  for  children  for  four  hundred  and  seven  years.  The 
rest  of  the  time  —  she  cannot  tell  exactly  the  number  of  years  — 
she  has  been  working  as  portress,  which  is  still  her  occupation. 
All  her  titles  and  all  her  rights  are  recorded  in  the  "documents  of 
conviction/'  a  book  whicli  she  has.  Information  concerning  this 
book  is  to  be  obtained  from  the  one  in  charge  of  the  scullery. 

These  delusions,  though  active,  at  present  produce  no  reaction 
on  the  part  of  the  patient  and  do  not  affect  her  lucidity.  The 
patient  is  quiet  and  is  a  useful  and  intelligent  worker.  She  works 
in  the  dining  room  of  her  ward,  sees  that  the  table  cloth  is  put  on 


270  MANUAL  OF  PSYCHIATRY, 

at  the  proper  time  and  that  the  slices  of  bread  are  regularly  dis- 
tributed. After  meals  she  helps  to  wash  the  dishes  and  watches 
over  the  work  of  her  helpers.  Between  meals  she  works  in  the 
nurses'  kitchen.  On  Sundays  she  writes  letters  for  other  patients 
who  are  unable  to  write.  The  letters  which  she  composes  are  per- 
fectly sensible,  and  the  spelling  is  tolerably  good,  wliich  indicates 
the  conservation  of  a  certain  amount  of  knowledge  acquired  pre- 
viously. But  her  activity  is  alway:^  in  the  same  direction  in  which 
it  has  been  for  a  number  of  years.  The  supervising  nurse  reports 
that  she  cannot  adapt  herself  to  new  work. 

Her  affections  have  completely  disappeared.  Her  children, 
whom  she  persists  in  calling  her  "babies,"  paid  her  a  visit  several 
years  ago.  She  recognized  them,  but  received  them  with  absolute 
indifference.  She  shows  no  attachment  to  any  one  about  her. 
^\^leneve^  any  nurse  or  patient  leaves  the  institution,  she  simply 
says:  "Another  will  soon  come  in  her  place." 

Delire  chronique  k  Evolution  systematique.  —  Iso- 
lated by  Magnan  from  the  poorly  defined  group 
of  paranoic  conditions,  delire  chronique  presents  a 
striking  analogy  to  certain  forms  of  dementia 
praecox,  which  fact  has  led  Kraepelin  to  include  it 
under  the  heading  of  paranoid  dementia.  Conform- 
ing to  French  usage,  I  shall  describe  it  as  a  separate 
morbid  entity,  which  appears  to  me  to  be  justi- 
fiable, at  least  provisionally,  in  view  of  the  following 
considerations : 

(1)  This  condition  appears  at  an  age  when  de- 
mentia pra3cox  is  already  rare  —  after  thirty  years 
in  the  majority  of  cases; 

(2)  The  delusions  present  perfect  systematiza- 
tion  and  a  regular  evolution,  which  is  unusual  in 
dementia  pra)cox; 

(3)  The  dementia  does  not  appear  for  many  years. 
Sometimes  it  does  not  appear  at  all,  even  when  the 
patient  has  reached  an  advanced  age  (Falret). 


DEMENTIA  PItECOX.  271 

The  name  "dementia  prsecox"  would  scarcely  be 
applicable  to  an  affection  usually  appearing  at  an 
adult  age,  and  in  which  intellectual  enfeeblement 
does  not  supervene  until  long  after  the  onset  — ■ 
twenty  years  or  more.  Though  we  may  consider 
this  disorder  as  being  very  closely  related  to  de- 
mentia prsecox,  it  would  seem  that  more  facts  are 
necessary  to  establish  the  identity  of  the  two  con- 
ditions. 

The  evolution  of  delire  chronique  occurs  in  four 
periods,  which  we  shall  consider  hastily,  for  the 
sjrmptoms  encountered  in  each  of  these  periods 
have  already  been  described,  and  it  is  but  the 
special  grouping  of  these  symptoms  that  imparts 
to  this  disease  its  characteristic  aspect. 

First  period:  incubation.  —  This  period  is  always 
a  prolonged  one.  The  personality  of  the  patient 
undergoes  a  slow  and  insensible,  though  profound, 
transformation.  The  symptoms  observed  at  the 
beginning  present  no  definite  character.  They 
consist  in  an  irritability  and  a  singular  'pessimism, 
with  which  are  often  associated  hypochondriacal 
ideas. 

Little  by  little  these  pathological  phenomena  be- 
come more  and  more  marked  and  develop  into  ideas 
of  persecution.  Suspiciousness  and  uneasiness  ap- 
pear first,  followed  later  by  delusional  interpreta- 
tions: the  patient  imagines  he  is  watched  as  he 
walks  in  the  street,  he  discovers  a  hidden  meaning 
in  a  conversation.  Illusions  of  all  the  senses,  but 
especially  those  of  hearing  and  of  smell,  gradually 
appear  as  the  affection  reaches  the  second  period. 


272  MANUAL  OF  PSYCHIATRY. 

Second  period:  systematization  of  the  delusions; 
appearance  of  hallucinations.  —  Hallucinations  are 
constant  and  affect  all  the  senses  except  vision. 
They  are  always  of  a  painful  character.  The  first 
to  appear  are  phonemes  (verbal  auditory  hallucina- 
tions), which,  vague  at  the  beginning,  assume  after 
a  certain  time  remarkable  distinctness.  They  are 
followed  by  the  appearance  of  hallucinations  of 
taste,  smell,  general  sensibility,  including  the  genital 
sense,  and,  later  on,  motor  hallucinations  also. 

Visual  hallucinations  are  extremely  rare,  if  ever 
present  at  all.  On  the  other  hand,  illusions  of  sight 
are  as  frequent  as  those  of  the  other  senses,  often 
taking  the  form  of  mistakes  of  identity. 

By  degrees  the  delusions  group  themselves  and 
become  systematized.  The  hallucinations  are  inter- 
preted and  explained.  The  patient  recognizes  the 
voices,  discovers  his  persecutors,  the  methods  they 
make  use  of,  and  the  aims  they  pursue.  As  he  is 
perfectly  convinced  of  the  reality  of  his  delusions, 
he  reacts,  seeking  to  protect  himself  against  his 
imaginary  enemies  and  to  find  justice.  The  means 
to  which  he  may  resort  are  infinitely  varied :  protests 
before  authorities  and  before  the  public,  frequent 
changing  of  residence,  and  but  too  often  assaults 
and  murder. 

As  the  disease  advances,  more  and  more  evident 
signs  of  psychic  disaggregation  appear:  echo  of  the 
thoughts,  autochthonous  ideas,  motor  hallucinations, 
etc. 

Third  period:  ideas  of  grandeur.  —  Some  authors 
regard  the  ideas  of  grandeur  as  a  logical  sequence  of 


DEMENTIA  PRECOX.  273 

those  of  persecution,  resulting  from  the  following 
line  of  reasoning,  which  the  patient  is  assumed  to 
pursue  more  or  less  consciously:  ''They  persecute 
me  so  unmercifully  and  with  such  stubbornness 
because  they  are  afraid  of  me  or  jealous  of  me." 
This  explanation  is  perhaps  appHcable  to  a  small 
number  of  cases,  but  not  generally  so. 

The  real  cause  of  the  ideas  of  grandeur  is  invariably 
mental  deterioration  which  makes  its  appearance  at 
this  period. 

These  ideas  are  of  all  possible  forms:  ideas  of 
wealth,  of  power,  or  of  transformation  of  the  per- 
sonality. One  patient  was  God  and  his  persecutor 
was  the  devil.  Another  reigned  over  the  planet 
Mars,  and  once  decided  to  destroy  the  earth  by 
means  of  aeroliths. 

Fourth  period:  dementia.  —  Mental  deterioration 
here  becomes  clearly  apparent.  Its  character  is 
very  similar  to,  if  not  identical  with,  that  of  de- 
mentia prsecox,  and  this  is  undoubtedly  strong  evi- 
dence of  a  close  relationship  existing  between  the 
two  diseases. 

Almost  always  some  stereotyped  delusions  per- 
sist as  a  last  remnant  of  the  former  system  of  delu- 
sions. 

The  evolution  of  the  disease  is  very  slow,  often 
requiring  twenty  or  thirty  years  for  its  comple- 
tion. 

The  prognosis  is  fatal  from  the  psychic  standpoint. 
But  the  morbid  process  does  not  affect  the  organic 
functions,  and  the  patients  may  live  to  an  old 
age. 


274  MANUAL  OF  PSYCHIATRY. 

DIAGNOSIS,    PROGNOSIS,    ETIOLOGY,    AND    TREATMENT 
OF   DEMENTIA   PR.ECOX   IN   GENERAL. 

Diagnosis.  —  This  is  based  upon : 

(a)  The  early  appearance  of  disorders  of  affec- 
tivity  and  of  the  reactions; 

(6)  The  delayed  appearance  of  intellectual  dis- 
orders proper  and  their  less  marked  intensity; 

(c)  The  contrast  existing  in  most  cases  between 
the  delusions  and  the  emotional  tone; 

(d)  The  purely  automatic  character  of  the  excite- 
ment and  of  most  of  the  reactions. 

It  is  at  the  beginning  that  the  greatest  difficulty 
in  diagnosis  is  encountered. 

Mental  confusion  is  to  be  distinguished  by  the 
much  more  pronounced  disorientation,  the  much 
more  real  disorder,  so  to  speak,  of  consciousness,  and 
by  the  symptoms  of  profound  denutrition,  some- 
times of  true  cachexia,  which  are  a  constant  mani- 
festation of  the  disease. 

General  paresis  is  distinguished  by  the  intellectual 
enfeeblement  en  masse,  by  its  characteristic  physical 
signs,  and  by  its  special  etiology. 

Delirium  tremens,  which  may  be  simulated  by  the 
delirious  outbreaks  marking  the  onset  of  dementia 
pra^cox,  is  recognized  by  the  pathognomonic  char- 
acter of  the  hallucinations,  by  the  very  pronounced 
allopsychic  disorientation  contrasting  with  the  in- 
tact autopsychic  orientation,  and  by  the  stigmata  of 
alcoholism. 

Alcoholic  hallucinosis  is  often  very  difficult  to  dis- 
tinguish from  the  delusional  form  of  dementia  pra?- 


DEMENTIA  PRECOX.  275 

COX.  Special  attention  must  be  paid  to  the  etiology 
of  the  case  and  to  the  evolution  of  the  disease,  which 
is  more  favorable  in  alcoholic  hallucinosis.  One 
should,  however,  be  very  guarded  in  rendering  a  diag- 
nosis as  well  as  a  prognosis.  In  practice  it  is  not  rare 
to  meet  with  chronic  alcoholics  who  present  after  an 
attack  of  alcoholic  hallucinosis  or  even  of  delirium 
tremens  the  symptoms  of  dementia  praecox  which 
subsequently  run  the  classical  course  and  to  which 
the  alcoholism  has  served  merely  as  a  portal  of  entry. 

Prognosis.  —  This  is  always  grave  as  the  usual 
outcome  is  dementia. 

The  mental  deterioration  is  sometimes  so  slight, 
it  is  true,  that  it  appears  only  as  a  scarcely  percepti- 
ble sluggishness  of  association  of  ideas,  a  certain 
degree  of  emotional  indifference,  and  a  tendency  to 
intellectual  fatigue. 

A  certain  number  of  patients  even  form  an  ex- 
ception to  the  general  rule  and  recover  completely. 
Such  cases  are  rare  and  are  to  be  accepted  only  with 
extreme  circumspection.  Many  of  the  apparently 
complete  recoveries  are  but  relative,  and  many  re- 
coveries considered  permanent  are  but  temporary; 
that  is  to  say,  they  are  mere  remissions. 

Indeed,  remissions  are  frequent  in  dementia  prae- 
cox. Their  duration  varies  within  very  wide  limits, 
from  a  few  hours  to  several  years.  It  is  not  ex- 
ceptional for  a  precocious  dement  to  come  out  of  his 
first  attack  apparently  unscathed,  resume  his  normal 
life  for  five,  six,  or  more  years,  suffer  a  recurrency, 
and  end  with  dementia. 

Dementia  prsecox  is  not  in  itself  a  fatal  disease. 


276  MANUAL  OF  PSYCHIATRY. 

It  may  terminate  fatally  from  the  complications  by 
which  it  is  sometimes  accompanied.  The  most  for- 
midable of  these  is  pulmonary  tuberculosis,  which  is 
apt  to  attack  patients  in  a  state  of  depression  or  in 
catatonic  stupor. 

Such  is  the  general  prognosis  of  dementia  prsecox. 
But  since  the  possibility  of  recovery  or  at  least  of 
long  remissions  exists  in  some  cases,  the  practical 
psycliiatrist  is  in  every  case,  considered  individually, 
confronted  with  the  problem  of  rendering  not  a 
general  but  a  special  prognosis. 

It  is  difficult,  not  to  say  impossible,  to  predict  the 
course  and  outcome  of  a  given  case.  Some  features 
of  the  disease  have,  however,  been  found  empiri- 
cally to  be  of  special  prognostic  significance,  and 
may  therefore  aid  the  physician  in  forming  an 
opinion. 

The  first  point,  one  that  should  never  be  lost  sight 
of,  is  that  only  those  cases  can  be  properly  regarded 
as  absolutely  incurable  in  which  there  is  actual 
mental  deterioration.  In  this  connection  the  most 
certain  and  most  constant  sign  of  mental  deteriora- 
tion is  indifference,  when  it  exists  independently  of 
any  marked  disorder  of  consciousness,  hallucinations, 
excitement,  or  stupor,  in  other  words,  when  it  ex- 
ists as  a  basic  disorder.  A  host  of  symptoms,  de- 
scriptions of  which  have  already  been  given  and 
which  need  not  here  again  be  entered  upon  (weak- 
ening of  attention,  inaction,  etc.),  are  seen  in  more 
or  less  close  association  with  indiff'erence ;  it  must, 
however,  be  insisted  on  that  their  significance  is 
subordinate  to  that  of  indifference. 


DEMENTIA  PRECOX.  277 

Aside  from  these  states  of  actual  deterioration 
the  prognosis  should  always  be  guarded.  Never- 
theless valuable  indications  may  be  gained  from  a 
study  of  the  combination  of  symptoms  before  the 
development  of  mental  deterioration ;  for  the  various 
forms  in  which  the  disease  appears  and,  in  the  same 
form,  the  predominance  of  one  or  another  symptom, 
afford  very  different  indications. 

There  is  but  little  to  be  said  concerning  the  simple 
form:  consisting  essentially  of  mental  deterioration, 
it  may  be  regarded  as  incurable  from  the  beginning. 
The  question  may  arise  whether  the  deterioration 
will  progress  or  will  remain  stationary.  Unfortu- 
nately there  is  no  sign  which  might  aid  in  forming  a 
judgment  on  this  point. 

The  catatonic  form  presents  the  greatest  chance  of 
cure.  Meyer  has  seen  20-25%  of  cases  terminate 
in  improvement  sufficient  to  enable  the  subjects  to 
take  their  place  again  in  life  in  society. 

Kraepelin  himself  has  observed  in  20%  of  his 
cases  remissions  so  complete  and  so  lasting  as  to 
resemble  cures.  I  do  not  believe  these  figures  are 
exaggerated,  but  may  be  rather  an  underestimation 
of  the  truth.  It  seems  clear,  therefore,  that  re- 
covery from  catatonia  is  a  possible  thing. 

Catatonic  symptoms  are  not  all  of  the  same 
gravity.  In  a  general  way,  states  of  excitement  are 
of  lesser  gravity  than  states  of  stupor,  the  latter  not 
being,  however,  always  incurable.  Negativism,  mor- 
bid suggestibility,  or  delusions  do  not  imply  a  par- 
ticularly unfavorable  prognosis  and  are  capable  of 
retrogression  and  complete  disappearance.     On  the 


278  MANUAL  OF  PSYCHIATRY. 

other  hand  stereotypy,  whether  of  speech,  move- 
ments, or  attitudes,  very  marked  incoherence,  sudden 
violent  and  unexplained  impulses,  not  having  their 
origin  in  a  delusion  or  a  hallucination,  have  an  un- 
favorable significance  and  generally  constitute  signs 
of  chronicity,  without,  however,  enabling  us  to 
predict  the  degree  of  mental  deterioration  to  which 
the  disease  may  lead.  These  symptoms  would  justify 
us  in  saying  fairly  definitely  that  the  patient  will 
not  get  well,  but  not  that  the  disease  will  be  arrested 
in  its  progress,  or  that  it  will  advance;  this  point 
should  always  be  reserved. 

The  delusional  forms  are  not  all  of  the  same 
gravity,  although  on  the  whole  the  prognosis  of 
delusional  dementia  pra3cox  is  more  grave  than  that 
of  catatonia.  Systematization  of  the  delusions  is 
almost  always  a  sign  of  chronicity.  I  say  chron- 
icity, but  not  tendency  toward  either  rapid  or  pro- 
found mental  deterioration;  for  there  are  types  of 
paranoid  dementia  with  active  and  well  systematized 
delusions  in  which  it  would  be  very  difficult  to  de- 
tect any  trace  of  mental  deterioration.  Such  cases 
approach  those  which  are  to-day  still  described  un- 
der the  name  of  delire  chronique  without  dementia 
and  which  have  been  insisted  on  by  Falret  and  his 
pupils,  when  they  have  maintained,  contrary  to 
Magnan,  that  the  period  of  dementia  may  be 
wanting  in  that  condition.  Hence,  the  indication 
of  systematized  delusions  is:  chronicity  very  prob- 
able, but  not  necessarily  dementia. 

This  probability  becomes  even  greater  when  the 
delusional  system  becomes  impoverished,  begins  to 


DEMENTIA   PRECOX.  279 

show  features  of  incoherence  and  absurdity,  and 
especially  when  the  delusions  cease  to  be  accom- 
panied by  adequate  affective  state  and  reactions. 
The  latter  principle  is  but  a  corollary  of  the  principle 
enunciated  above,  namely,  that  indifference  without 
an  obvious  basis  is  a  symptom  of  incurability. 

As  signs  of  unfavorable  prognosis  in  paranoid 
dementia  should  be  mentioned,  further,  multiplicity 
of  hallucinations  (when  occurring  independently  of 
mental  confusion),  in  particular  psychomotor  hal- 
lucinations and  those  of  general  sensibility,  also 
transformation  of  the  personality. 

These  are,  briefly  sketched,  the  data  which  enable 
us  in  a  certain  measure  to  foresee  the  course  in  a 
given  case  of  dementia  prsecox.  One  must  not  be 
misled  into  taking  the  value  of  these  criteria  to  be 
any  greater  than  that  of  provisional  landmarks;  in 
the  present  state  of  our  knowledge  of  psychiatry 
skill  in  prognosis  is  dependent  chiefly  upon  appre- 
ciation of  fine  shades,  which  comes  only  with  long 
experience  in  mental  diseases. 

As  being  of  prognostic  significance  may  be  men- 
tioned further  very  decided  ''shut-in"  make-up 
(see  p.  284)  and  insidious  onset,  both  points  being 
of  grave  import,  while  abrupt  onset  in  a  subject  of 
normal  mental  make-up  affords  greater  hope  of  im- 
provement or  recovery. 

Etiology.  —  Statistics  show  that  dementia  prsecox 
is  a  disease  chiefly  of  young  life.  According  to 
Kraepelin,  in  60%  of  the  cases  it  begins  before  the 
twenty-fifth  year.  It  is  rare  after  the  age  of  thirty. 
It  seems,  however,  difficult  to  state  at  what  age  it 


280  MANUAL  OF  PSYCHIATRY. 

entirely  ceases  to  occur.  Certain  psychoses  identical 
with  it  in  symptoms  and  evolution  are  met  with  at 
advanced  ages.  But  such  irregularities  are  not 
limited  to  psychiatry.  Miliary  tuberculosis  is  an 
affection  chiefly  of  childhood  and  youth;  it  is,  how- 
ever, also  met  with  in  elderly  people.  Is  it  surpris- 
ing, therefore,  that  a  psychosis  presenting  all  the 
features  of  dementia  prsecox  should  be  found  to 
occur  by  way  of  exception  in  middle-aged  or  even 
in  old  individuals? 

Heredity  is  to  be  regarded  as  the  essential  cause  of 
this  disorder. 

Severe  infections,  overwork,  grief,  and  trauma- 
tisms are  occasionally  found  in  the  history  of  de- 
mentia praecox.  (For  a  discussion  of  contributing 
causes  see  pp.  9-12.)  Von  Muralt  has  observed 
several  cases  of  catatonia  following  traumatism. 
I  saw  a  case  of  catatonia  in  which  the  disorder 
was  preceded  by  a  very  severe  attack  of  scarlet 
fever;  also  a  case  of  paranoid  dementia  in  which 
the  mental  trouble  was  preceded  by  typhoid  fever. 

The  nature  of  the  disease  has  so  far  escaped 
us,  and  we  must  be  content  for  the  present  with 
hypotheses. 

According  to  some  authors  dementia  praecox  results 
from  an  arrest  of  intellectual  development;  the 
brain  ceases  to  acquire  new  impressions,  being  ex- 
hausted by  pre\'ious  efforts  which  were  too  great  for 
the  energy  which  it  originally  possessed.  This  ex- 
planation, assuming  it  to  be  correct,  cai^  account  for 
but  a  small  number  of  cases.  In  reality,  in  most  of 
the  patients  we  observe  not  a  simple  statu  quo,  but  a 


DEMENTIA  PR^(DOX.  281 

true  retrogression.  Facts  that  have  been  acquired 
partly  disappear,  or  at  least  cease  to  be  coordinated 
so  as  to  give  rise  to  generalized  ideas.  Moreover, 
the  disorders  of  affectivity  and  of  the  will  cannot  be 
accounted  for  by  simple  arrest  of  development. 

According  to  Kraepelin's  hypothesis  dementia 
prsecox  is  a  disease  of  autointoxication.  Many  of 
the  physical  symptoms  described  above  resemble  the 
phenomena  by  which  intoxications  of  exogenous  or 
of  endogenous  origin  are  usually  manifested :  epilepti- 
form attacks,  hysteriform  disturbances,  disorders  of 
the  circulation  and  of  the  secretions,  and  alterations 
of  the  general  nutrition. 

Possibly  the  poison  is  the  consequence  of  a  disorder 
jof  secretion  of  the  genital  organs.  The  frequent  ap- 
pearance of  the  first  symptoms  at  the  age  of  puberty, 
or  in  the  female  at  the  time  of  her  first  childbirth, 
and  the  occasional  development  of  the  disease  in  in- 
terrupted stages,  each  corresponding  to  a  period  of 
pregnancy,  are  arguments  in  favor  of  this  hypothesis. 

A  suggestive  and  far-reaching  hypothesis  bearing 
on  the  pathogenesis  of  dementia  prsecox  has  recently 
been  advanced  by  Adolf  Meyer. 

It  is  quite  true  that  in  some  cases  of  dementia 
prsecox  we  find  a  history  of  some  infection  or  trauma- 
tism which  is  seemingly  to  a  greater  or  lesser  extent 
to  be  held  responsible  for  the  mental  disturbance. 
But  it  is  equally  true  that  in  the  great  majority  of 
cases,  as  far  as  we  know,  the  disorder  develops  with- 
out any  such  cause. 

From  Meyer's  point  of  view  such  a  clinical  picture 
as  that  of  dementia  prsecox  may  be  the  result  of  an 


282  MANUAL  OF  PSYCHIATRY. 

acquisition  and  unchecked  development  of  vicious 
mental  habits  or  of  abnormal  "types  of  reaction" 
which  ultimately  replace  by  substitution  healthy 
and  efficient  mental  reactions  such  as  are  necessary 
in  our  constant  acts  of  adjustment  to  our  usual  en- 
vironment as  well  as  to  newly  arising  situations. 

The  importance  of  this  view  lies  in  its  bearing  on 
therapeutics  and,  to  a  still  greater  extent,  on  pro- 
phylaxis. 

To  quote  from  the  original  paper  :^ 

"  Every  individual  is  capable  of  reacting  to  a  very  great  variety 
of  situations  by  a  limited  number  of  reaction  types. " 

"  The  full,  wholesome,  and  complete  reaction  in  any  emergency 
or  problem  of  activity  is  the  final  adjustment,  complete  or  incom- 
plete, but  at  any  rate  clearly  planned  so  as  to  give  a  feeling  of 
satisfaction  and  completion.  At  'other  times  there  results  merely 
an  act  of  perplexity  or  an  evasive  substitution.  Some  of  the  reac- 
tions to  emergencies  or  difficult  situations  are  mere  temporizing 
attempts  to  tide  over  the  difficulty,  based  on  the  hope  that  new 
interests  crowd  out  what  would  be  fruitless  worry  or  disappoint- 
ment; complete  or  incomplete  forgetting  is  the  most  usual  remetly 
of  the  results  of  failures,  and  just  as  inattention  and  distraction 
correct  a  tendency  to  overwork,  so  fault-finding  with  others,  or 
imaginative  thoughts,  or  praying,  or  other  expedients,  are  rehwl 
upon  to  help  over  a  disappointment,  and,  as  a  rule,  successfully. 
Otlicr  responses  are  much  more  apt  to  become  harmful,  dangerous, 
uncontrollable  —  a  rattled  fuml)ling,  or  a  tantrum,  or  a  hysterical 
fit,  or  a  merely  partial  suppression,  an  undercurrent,  an  uncor- 
rected fal.se  lingering  attitude,  or  whatever  the  reaction  tyjie  of 
the  iiuhvidual  may  be.  What  is  first  a  remedy  of  difficult  situa- 
tions can  become  a  miscarriage  of  the  reme(hal  work  of  life,  just 
as  fever,  from  being  an  agent  of  self-defence,  may  become  a  danger 
and  more  destructive  than  its  source.  In  the  cases  that  tend  to  go 
to  deterioration  certain  types  of  reactions  occur  in  such  frequency 

'   Adolf  Meyer.      Fumhmu-ntal  Conceptions  of  Dementia  ProEcox. 
British  M(;d.  Jour.,  Sept.  29,  1906. 


DEMENTIA  PRECOX.  283 

as  to  constitute  almost  pathognomonic  empirical  units.  I  would 
mention  hypochondriacal  trends,  ideas  of  reference,  fault-finding 
or  suspicions,  or  attempts  to  get  over  things  with  empty  harping, 
unaccountable  dream-like,  frequently  nocturnal,  episodes,  often 
with  fear  and  hallucinations,  and  leading  to  strange  conduct,  such 
as  the  running  out  into  the  street  in  nightdress,  etc.,  or  ideas  of 
strange  possessions  with  hallucinatory  dissociations,  or  the  occur- 
rence of  fantastic  notions.  All  these  appear  either  on  the  groimd 
of  a  neurasthenoid  development,  or  at  times  suddenly,  on  more 
or  less  insufficient  provocation,  with  insufficient  excuse,  but  often 
enough  with  evidence  that  the  patient  was  "habitually  dreamy, 
dependent  in  his  adjustment  to  the  situations  of  the  world  rather 
on  shirking  than  on  an  active  aggressive  management,  scattered 
and  distracted  either  in  all  the  spheres  of  habits  or  at  least  in  some 
of  the  essential  domains  of  adjustment  which  must  depend  more 
or  less  on  instinct  or  habit.  On  this  ground  reaction  types  which 
also  occur  in  milder  forms  of  inadequacy,  in  psychasthenia  and 
hysteria  or  in  religious  ecstasy,  etc.,  turn  up  on  more  inadequate 
foundation  and  with  destructive  rather  than  helpful  results.  We 
thus  obtain  the  negativism  no  longer  as  healthy  indifference  and 
more  or  less  self-sparing  dodging,  but  distinctly  as  an  uncontrol- 
lable, unreasoning,  blocking  factor.  We  obtain  stereotypies  not 
merely  as  substitutive  reactions  and  automatisms  on  sufficient 
cause  such  as  everybody  will  have,  but,  as  it  were,  as  a  reaction  of 
dead  principle  in  a  rut  of  least  resistance.  We  see  paranoic  devel- 
opments with  the  same  inadequacy  of  starting  point  and  failure  in 
systematization,  and  in  holding  together  the  shattered  personahty, 
etc." 

"  Therapeutical!}',  this  way  of  going  at  the  cases  will  furnish  the 
best  possible  perspectives  for  action.  We  stand  here  at  the  begin- 
ning of  a  change  which  will  make  psychiatry  interesting  to  the 
family  physician  and  practitioner.  As  long  as  consumption  was 
the  leading  concept  of  the  dreaded  condition  of  tuberculosis,  its 
recognition  very  often  came  too  late  to  make  therapeutics  tell.  If 
dementia  is  the  leading  concept  of  a  disorder,  its  recognition  is 
the  declaration  of  bankruptcy.  To-day  the  physician  thinks  in 
terms  of  tuberculous  infection,  in  terms  of  what  favours  its  devel- 
opment or  suppression;  and  long  before  "consumption"  comes 
to  one's  mind,  the  right  principle  of  action  is  at  hand —  the  change 
of  habits  of  breathing  poor  air,  of  physical  and  mental  ventUation, 
etc.     In  the  same  way,  a  knowledge  of  the  working  factors  in  de- 


284  MANUAL  OF  PSYCHIATRY. 

mentia  prsecox  will  put  us  into  a  position  of  action,  of  habit-training, 
and  of  regulation  of  mental  and  physical  hygiene,  as  long  as  the 
possible  "mental  consumption"  is  merely  a  perspective  and  not 
an  accomphshctl  fact.  To  be  sure,  the  conditions  are  not  as  simple 
as  with  an  infectious  process.  The  balancing  of  mental  metabolism 
and  its  influence  on  the  vegetative  mechanisms  can  miscarry  in 
many  ways.  The  general  principle  is  that  many  individuals  can- 
not afford  to  count  on  unlimited  elasticity  in  the  habitual  use  of 
certain  habits  of  adjustment,  that  instincts  will  be  undermined  by 
jjersistent  misapplication,  and  the  delicate  balance  of  mental  ad- 
justment and  of  its  material  substratum  must  largely  depend  on 
a  maintenance  of  sound  instinct  and  reaction  type." 

Meyer's  views  gain  additional  significance  in  the 
light  of  the  more  recent  contribution  of  August 
Hoch,^  who  finds  in  a  large  percentage  of  his  cases  of 
dementia  prsecox  (51-66%)  evidences  of  a  peculiar 
mental  make-up  which  he  has  termed  "shut-in  per- 
sonality." This  make-up  he  defines  as  follows: 
"Persons  who  do  not  have  a  natural  tendency  to  be 
open  and  to  get  into  contact  with  the  environment, 
who  arejraticent,  seclusive,  who  cannot  adapt  them- 
selves to  situations,  who  are  hard  to  influence,  often 
sensitive  and  stubborn,  but  the  latter  more  in  a 
passive  than  an  active  way.  They  show  little  in- 
terest in  what  goes  on,  often  do  not  participate  in 
the  pleasures,  cares,  and  pursuits  of  those  about 
them;  although  often  sensitive  they  do  not  let 
others  know  what  their  conflicts  are;  they  do  not 
unburden  their  minds,  are  shy,  and  have  a  tendency 
to  live  in  a  world  of  fancies.  This  is  the  shut-in 
personality."^  And    he    adds    further:     "Wliat    is, 

'  Constitutional  Factors  in  the  Dementia  Praecox  Group.  Rev.  of 
Neurol,  and  Psychiatry,  Aug.,  1910. 


DEMENTIA  PRECOX.  285 

after  all,  the  deterioration  in  dementia  prsecox  if 
not  the  expression  of  the  constitutional  tendencies 
in  their  extreme  form,  a  shutting  out  of  the  outside 
world,  a  deterioration  of  interests  in  the  environ- 
ment, a  living  in  a  world  apart?"  For  purposes  of 
control  Hoch  has  examined  the  histories  of  his  cases 
of  manic  depressive  insanity  and  failed  to  find  plain 
evidences  of  a  marked  shut-in  personality.^ 

Pathological  anatomy.  —  Until  recently  most  psy- 
chiatrists placed  dementia  prsecox  among  the  so- 
called  functional  disorders.  The  newer  studies  have, 
however,  revealed  fairly  constant,  though  not 
pathognomonic,  anatomical  changes.  Alzheimer 
and  others  working  by  his  methods  have  found  prod- 
ucts of  nerve  cell  degeneration  within  nerve  cells, 
in  the  clear  spaces  around  them,  and  especially  in 
the  perivascular  spaces. ^  Southard,  having  selected 
37  cases  of  dementia  prsecox  showing  at  autopsy  no 
coarse  complicating  features  like  brain  atrophy,  in- 
tracranial arteriosclerosis,  etc.,  has  found  in  19  foci 
of  gliosis  distinctly  palpable  in  the  fresh  brains.^ 
Rosanoff,  making  use  of  an  improved  method  for 


1  Journ.  of  Nerv.  and  Mont.  Dig.,  Apr.,  1909. 

2  Alzheimer.  Beitrdge  zur  Kennlniss  der  pathologischen  Neuroglia 
und  ihrer  Beziehungen  zu  den  Abbauvorgdngen  in  nervosen  Gewebe. 
Histologische  und  histopathologische  Arbeiten  liber  die  Gross- 
hirnrinde,  3,  1910. — Sioli.  Histologische  Befunde  bei  Dementia 
Proecox.  Allg.  Zeitschr.  f.  Psychiatrie,  Vol.  LXVI,  p.  195,  1909.  — 
Orton.  xl  Study  of  the  Brain  in  a  Case  of  Catatonic  Hirntod.  Amer. 
Journ.  of  Insanity,  Apr.,  1913. 

^  Southard.  A  Study  of  the  Dementia  Proecox  Group  in  the  Light 
of  Certain  Cases  Showing  Anomalies  or  Scleroses  in  Particular  Brain 
Regions.     Amer.  Journ.  of  Insanity,  July,  1910. 


286  MANUAL  OF  PSYCHIATRY. 

measuring  brain  atrophy  consisting  essentially  in 
observing  the  relationship  between  cranial  capacity 
and  brain  weight,  has  found  very  close  and  con- 
stant correlation  between  the  degree  of  mental  de- 
terioration observed  clinically  and  that  of  atrophy 
found  at  autopsy  in  cases  of  dementia  prsecox;  from 
this  he  has  drawn  the  conclusion  that  "dementia 
prsecox  is  associated  in  some  way  with  changes  in 
the  brain  which  lead  to  atrophy."^ 

Treatment.  —  Excitement,  refusal  of  food,  danger- 
ous tendencies  are  treated,  as  they  arise,  by  the 
methods  already  described  in  the  first  part  of  this 
book.  An  effort  should  be  made  to  combat  stereo- 
typy in  all  its  forms  by  suggestion  and  by  diversion 
and  occupation.  Employment  at  useful  labor  is 
desirable  also  from  the  economic  standpoint;  preco- 
cious dements  constitute  a  large  proportion  of  in- 
stitution workers  and  thus  contribute  toward  their 
support. 

^  Rosanoff.  A  Study  of  Brain  Atrophy  in  Relation  to  Insanity. 
Amer.  Journ.  of  Insanity,  July  1914. 


^9 


CHAPTER  IV.. 

PARANOIA. 

Paranoia  is  to  be  looked  upon  as  the  development  of 
a  morbid  germ  the  existence  of  which  manifests  itself 
in  early  life  by  anomalies  of  character.  These  anomalies 
may  be,  to  use  the  apt  expression  of  Seglas,  "summarized 
in  two  words:  conceit  and  suspicion."  At  a  certain  time 
the  pathological  tendencies  of  the  subject  find  their  ex- 
pression in  a  fixed  idea,  and  the  delusional  state  is 
established. 

Onset.  —  Sometimes  it  is  slow  and  gradual,  much  more 
frequently  rapid,  almost  sudden. 

In  the  first  case  the  dominant  traits  of  the  personality 
become  accentuated  little  by  little.  The  patient  grows 
more  and  more  suspicious  and  vain  and  believes  him- 
self to  be  the  object  of  malevolent  or,  on  the  contrary, 
admiring  reflections.  Delusional  interpretations  be- 
come more  and  more  numerous  until  finally  the  fixed 
idea  appears,  an  idea  of  persecution  or  of  grandeur, 
around  which  a  whole  delusional  system  is  subse- 
quently built  up. 

In  the  second  case  the  fixed  idea  is  primary  in  relation 

*  Leroy.  Les  persecutes  persecuteurs.  These  de  Paris,  1896.  — ■ 
Ballet  et  Roubinowitch.  Les  persecutes  persecuteurs.  —  Magnan 
Lemons  cliniques. 

287 


68  MANUAL  OF  PSYCHIATRY. 

to  the  delusional  interpretations.  Sometimes  the  fixed 
idea  appears  in  childhood/  as  in  a  case  of  Mangan's: 
the  boy  when  questioned  concerning  his  vocation  replied 
that  he  \yas  going  to  become  a  pope.  Sander  has  de- 
scribed this  form  under  the  name  paranoia  originaire. 

Usually  the  fixed  idea  appears  at  a  later  period,  in 
youth  or  in  adult  age.  Often  it  is  based  upon  some 
real  fact  the  significance  of  which  the  patient  misin- 
terprets or  the  importance  of  which  he  exaggerates: 
perfectly  justifiable  disciplinary  measures  to  which  he 
is  subjected,  loss  of  money,  or  sometimes,  indeed,  a  true 
injustice,  against  which.  Jiowever.  nothing  can  be^^ohe^ 
may  determine  the  onset  of  the  disease.  Often,  also,  it 
has  for  its  basis  the  extreme  credulity  of  the  patient,  who 
takes  in  earnest  a  simple  pleasantry  or  some  idle  remark. 
"  He  resembles  Napoleon,"  was  once  remarked  by 
some  one  in  the  presence  of  a  psychopath.  Immediately 
the  latter  conceived  the  idea  that  he  belonged  to  the 
royal  family  and  that  he  was  "  the  Master  of  France," 
and  this  formed  the  starting  point  of  his  system  of 
delusions.  w 

Fundamental  features  of  the  disease.  —  As  soon  as 
the  theme,  that  is  to  say  the  fixed  idea,  is  formed,  the 
disease  develops  very  rapidly  and  is  characterized  by: 

(1)  The  immutability  of  the  basic  fixed  idea; 

(2)  The  absolute  faith  which  the  patient  has  in  his 
delusions ; 

(3)  The  apparent  logic  of  the  delusional  system; 

(4)  The  promptness  and  intensity  of  the  reactions; 

(5)  The  absence  or  at  least  extreme  rarity  of  hallu- 
cinations and  the  presence  of  numerous  false  interpreta- 
tions; 


PARANOIA.  289 

(6)  The  absence  of  mental  deterioration  regardless  of 
the  length  of  time  that  the  disease  has  last-ed.  /  ^ 

The  following  brief  abstract  from  the  history  of  a 
case  illustrates  these  characteristics  in  a  somewhat 
schematic  fashion, 

A  schoolmaster,  who  was  a  man  of  average  intelligence,  but 
suspicious  and  conceited,  failed  to  receive  a  promotion  which  he 
believed  he  had  a  right  to  expect.  The  idea  that  he  was  the  victim 
of  a  grave  injustice  arose  in  his  mind  and  never  .left  it  {immuta- 
bility  of  the  fixed  idea).  The  reasonings  of  his  friends  and  relatives 
could  not  alter  his  conviction  and  failed  to  dissuade  him  from 
addressing  a  letter  of  strong  protestation  to  the  school  director 
{absolute  faith  in  his  delusions,  promptness  and  intensity  of  the  reac- 
tions). This  producing  no  effect  other  than  the  loss  of  his  position, 
he  applied  to  the  minister  of  public  instruction,  to  the  president  of 
the  republic,  to  the  tribunals.  He  found  no  justice,  but  neverthe- 
less retained  confidence  in  the  excellence  of  his  cause,  attributing 
his  successive  disappointments  to  dishonesty  of  the  representatives 
of  authority  and  justice,  who  he  claimed  were  in  league  against 
him  because  his  high  intellect  overshadowed  them.  Everything 
now  became  clear  to  him ;  he  understood  the  distrust  shown  towards 
him  and  the  attention  which  he  attracted  wherever  he  went  (appar- 
ent logic  of  the  delusions,  false  interpretations).  Finally  committed, 
he  continued  to  protest  against  his  persecutors,  among  whom  were 
included,  as  might  be  expected,  the  physician  who  treated  him  and 
the  police  officer  who  arrested  him;  the  memory  still  remains 
perfect  and  the  mind  lucid,  although  the  disease  has  now  lasted 
over  25  years  {absence  of  mental  deterioration). 

It  is  often  stated  that  the  delusions  of  paranoiacs 
are,  in  a  manner,  logical;  that  is  to  say,  when  the  fixed 
idea  once  appears  the  secondary  delusional  conceptions 
are  the  natural  outcome.  Thus  presented  this  sta,te- 
ment  is  not  correct.  In  fact,  if  these  patients  pos- 
sessed a  faultless  logic  it  would  render  apparent  to 
them  the  inconsistency  of  their  fixed  idea,  which  would 
be  immediately  abolished.     It  is  quite  true  that  these 


290  MANUAL  OF  PSYCHIATRY. 

patients  are  very  apt  to  use  and  abuse  deductions  and 
syllogisms,  which  trait  has  gained  for  them  the  name  of 
the  reasoning  insane.  But  their  logic  is  only  apparent; 
their  reasoning  is  always  tainted  with  the  same  original 
vice  that  leads  them  to  the  systematic  rejection  of 
arguments  opposing  their  ideas,  and  the  ready  accep- 
tance of  hypotheses  which  arise  in  their  minds  as  a 
result  of  their  pathological  preoccupations.  Hence 
their  delusional  interpretations,  which  become  more 
numerous  each  day  and  upon  which  they  base  their 
arguments,  and  the  childish  character  of  the  proofs 
which  they  accumulate.  A  vague  word  or  an  evasive 
reply  often  suffices  to  convince  them  that  their  point 
of  view  has  been  adopted  and  that  their  cause  has  been 
accepted.  The  concessions  occasionally  made  by  those 
against  whom  their  delusions  are  directed,  become,  in 
their  eyes,  ample  proof  that  these  people  admit  their 
guilt;  thus  misinterpreted  chance  occurrences  serve  to 
feed  the  system  of  delusions. 

Quite  frequently  their  reasoning,  subtle  and  plausible, 
though  radically  false,  is  imposed  upon  suggestible 
individuals  or  upon  those  of  shallow  minds.  Thus 
they  often  have  defenders  who  show  more  zeal  than 
intelligence.  The  history  of  the  famous  Sandon  presents 
such  an  example. 

Forms.  — "  According  to  their  special  morbid  ten- 
dencies paranoiacs  may  be  classed  in  different  groups: 
the  litigious  paranoiacs  (paranoia  querulens  of  the 
Germans),  who  prosecute  their  imaginary  rights  in 
the  courts;  the  hypochondriacal  paranoiacs,  who,  believ- 
ing themselves  to  have  been  once  improperly  treated  by 
a  physician,  bear  a  grudge  against  all  physicians  whom 


PARANOIA.  291 

they  may  meet  in  the  course  of  their  treatment,  and 
annoy  them  in  various  ways;  the  filial  paranoides, 
who  believe  that  they  have  found  their  father  in  some 
stranger,  whom  they  constantly  annoy  with  their 
expressions  of  tenderness  and  with  their  claims. 
Another  group  is  formed  by  the  amorous  paranoiacs: 

Teulat,  the  lover  of  Princess  de  B ,  was  a  splendid 

example  of  this  type."  (Magnan.) 

To  the  preceding  groups  should  be  added  the  jealous 
paranoiacs,  in  whom  the  delusions  assume  the  form  of 
morbid  jealousy;  inventors  who  are  indignant  for  the 
rejection  of  their  fantastic  inventions;^  mystics  and 
founders  of  religions  who  often  succeed  in  gathering 
beneath  their  banners  an  imposing  train  of  feeble- 
minded, or  at  least  unbalanced,  individuals,  etc. 

The  list  might  be  prolonged  indefinitely;  it  is  useless, 
however,  for  whatever  be  the  nature  of  the  fixed  idea, 
the  clinical  characteristics  of  the  delusional  state  do 
not  vary. 

Diagnosis.  —  The  first  question  that  may  arise  in  the 
mind  of  the  physician  is,  Are  the  ideas  of  the  subject 
delusional  or  not?  It  is  not  always  easy  to  answer  this 
question.  Delusions  sometimes  appear  very  probable, 
while,  on  the  other  hand,  well-based  claims  may  resemble 
the  delusions  of  reasoning  insanity  on  account  of  the 
obstinacy  with  which  they  are  urged.  Only  by  a  very 
careful  examination  of  each  case  can  errors  be  avoided. 

The  diagnosis  is  to  be  based  upon  the  fundamental 
characters  enumerated  above;  all  these  characters  in 
combination  are  not  observed  in  any  other  psychosis. 

*  Delarras.  Contribution  a  I'etude  du  delire  des  inventeurs.  These 
de  Bordeaux,  1900. 


292  MANUAL  OF  PSYCHIATRY. 

In  favor  of  paranoid  dementia  are  mental  deterio- 
ration and  the  more  mobile  character  of  the  delusions. 
In  delire  chronique  there  are  the  constant  presence  of 
hallucinations  and  a  progressive  evolution  of  the  dis- 
ease. In  the  alcoholic  delusion  of  jealousy  we  find  less 
perfect  systomatization,  the  constant  presence  of  hallu- 
cinations, the  stigmata  of  alcoholism,  and  the  tendency 
towards  recovery. 

Prognosis  and  treatment.  —  Reasoning  insanity  is  a 
chronic,  incurable  affection  which,  as  we  have  seen, 
entails  no  mental  deterioration. 

The  violence  of  the  reactions  almost  always  renders 
commitment  necessary.  There  are  no  known  means  for 
combating  the  delusions.  Psychic  treatment  has  no 
influence  whatever. 


CHAPTER  V. 

MANIC  DEPRESSIVE  PSYCHOSES.^ 

Manic  depressive  insanity  is  manifested  in  attacks 
presenting  a  double  characteristic:  a  tendency 
towards  recovery  without  intellectual  enfeebleraent 
and  a  tendency  towards  recurrency.  From  a  symp- 
tomatic standpoint  the  attacks  are  of  three  types, 
which  I  shall  describe  successively: 

Manic  type; 

Depressed  type; 

Mixed  types. 

§  1.   Manic  Type. 

Mania  presents  itself  in  three  principal  forms: 
simple  mania,  delusional  mania,  and  confused  mania. 
We  shall  first  study  simple  mania,  which,  more 
clearly  than  the  other  forms,  exhibits  the  following 
four  fundamental  symptoms  of  the  disease: 

Flight  of  ideas; 

Morbid  euphoria  and  irritability; 

Impulsive  character  of  the  reactions; 

Motor  excitement. 


^  Kraepelin.  Lehrbuch  der  Psychiatrie,  Vol.  II.  —  Weygandt. 
Ueber  das  manisch-depressives  Irresein.  Berlin,  klin.  Woch.,  1901, 
Nos.  4  and  5. 

293 


294  MANUAL  OF  PSYCHIATRY. 

Simple  Mania.  —  Prodromata. — The  phenomena  of 
maniacal  excitement  are  almost  constantly  preceded 
by  a  period  of  depression  characterized  by  diminution 
of  psychic  activity,  which  sometimes  amounts  to  a 
veritable  melancholic  state.  Later  on  we  shall  see 
the  importance  of  this  prodromal  period  as  an  argu- 
ment for  the  unity  of  manic  depressive  insanity. 

External  aspect. — The  face  of  the  maniac  is  flushed, 
the  eyes  brilliant,  the  expression  happy  and  animated. 
The  manner  and  gestures  indicate  a  state  of  ease  con- 
trasting often  with  the  usual  timidity  of  the  patient. 
The  dress  is  showy,  ridiculous,  and  ornamented  with 
gaudy  trinkets;  the  clothes  are  disordered,  perhaps 
put  on  inside  out.  In  women  a  bodice  excessively 
decollete  and  the  skirt  raised  too  high  show  also  the 
erotic  tendencies. 

Intellectual  disorders.  — Lucidity  is  perfect,  orienta- 
tion and  memory  are  intact. 

The  attention,  very  mobile,  is  distracted  by  all  external 
impressions. 

Associations  of  ideas,  uncontrolled,  are  formed  at 
random  from  similarities  of  sound,  superficial  resem- 
blances, coexistences  in  time  and  space,  etc.  Flight 
of  ideas  is  here  encountered  in  its  typical  form. 

These  two  sym})toms,  mobility  of  attention  and 
■flight  of  ideas,  are,  as  we  have  already  seen,  an  expression 
of  enfeeblement  of  the  normal  psychic  activity  and 
of  the  predominance  of  mental  automatism.  Under 
these  conditions  the  capacity  for  intellectual  labor  is 
diminished. 

The  judgment,  which  is  largely  dependent  upon  asso- 
ciations   of    ideas,    is    always    profoundly    disordered. 


MANIC  DEPRESSIVE  PSYCHOSES.  295 

Though  occasionally  the  patient  surprises  one  by  the 
accuracy  of  his  observation,  it  is  always  the  result 
of  a  sort  of  automatic  appreciation  bearing  upon  some 
isolated  fact.  But  since  judgment  necessitates  the 
systematic  grouping  of  a  very  considerable  number 
of  ideas,  it  is  here  cither  absent  or  at  least  impaired. 
A  maniac  who  notices  some  sHght  defect  in  the  dress 
of  the  examiner  is  incapable  of  appreciating  the  impor- 
tance of  an  event  or  of  an  act. 

Affective  disorders.  —  These  consist  in  morbid  euphoria 
and  irritability. 

The  euphoria  is  often  very  marked.  Many  patients 
after  recovery  declare  that  they  had  never  felt  so  happy 
as  they  did  during  the  attack.  The  maniac  is  pleased 
with  everything,  and  the  contrast  is  particularly  strik- 
ing when  the  excitement  follows  a  period  of  depression 
(insanity  of  double  form).  The  most  imperturbable 
optimism  replaces  the  pessimism  of  past  days.  Of 
disease  insight  there  is  no  question  at  all;  the  subject 
"never  before  felt  so  well";  if  he  is  "somewhat  ner- 
vous "  the  fault  is  with  his  relatives,  the  physicians^  or 
the  nurses,  who  constantly  interfere  with  him.  With  his 
intelligence  and  activity  he  could  "  easily  conduct  im- 
portant and  gigantic  enterprises."  If  he  were  allowed 
liberty  of  action,  he  would  show  everybody  what  he  \r 
capable  of. 

Sad  impressions  are  dismissed  with  a  vague  remarl 
or  a  joke.  A  maniac,  reminded  of  the  loss  of  his  fortune 
in  a  fire  (which  incidentally  was  the  cause  of  his  disease), 
replied  laughingly:  "Money  does  not  bring  happiness, 
and  besides  I  shall  have  earned  twice  as  much  six  months 
from  now." 


296  MANUAL  OF  PSYCHUTRY. 

This  optimism,  however,  is  never  so  absurd  as  that 
of  general  paretics  or  of  senile  dements.  Dumas  cites 
the  case  of-  a  general  paretic  who,  reminded  of  the 
recent  death  of  his  two  little  daughters,  replied:  "  Well, 
well!  I  shall  resuscitate  them."  A  maniac  would  never 
have  given  such  an  answer. 

The  irritability  is  e\ddent  in  the  \'iolent  outbursts  of 
anger  which  occur  on  the  slightest  provocation.  The 
maniac  will  bear  no  contradiction  and  will  accept  no 
suggestions. 

The  moral  sense  is  always  diminished;  the  sense  of 
propriety  is  greatly  affected.  The  maniac  is  cynical, 
dishonest,  and  mischievous.  "  He  lies,  cheats,  and 
steals  \\dthout  the  least  scruple.  He  allows  himself 
anything  that  in  others  he  would  condemn  "  (Wernicke). 
Quite  frequently  he  will  tease  and  inock  others.  If  in 
the  midst  of  his  rambling  speech  some  pointed  or 
amusing  remark  occurs,  it  is  always  at  the  expense  of 
others. 

Erotic  tendencies  form  an  integral  part  of  the  picture: 
the  patients  abandon  themselves  to  them  without 
shame.  Men  pre\'iously  exemplary  in  habits  go  around 
with  prostitutes.  Young  girls,  normally  very  reserved 
in  their  manner,  offer  themselves  to  everybody. 

One  frequently  sees  maniacs  indulging  in  alcoholic 
excesses. 

The  patient  is  incapable  of  appreciating  the  signifi- 
cance of  his  acts  either  before  or  after  they  are 
accomplished.  The  most  deprecable  acts  are  dis- 
played \\\ih  com})lacency  and  become  the  object  of 
cynical  pleasantries;  compunction  and  scruples  are 
absent. 


MANIC  DEPRESSIVE  PSYCHOSES.  297 

Reactions.  —  The  erethism  of  the  psychomotor  centers, 
constant  in  mania,  gives  rise  to  maniacal  excitement 
the  elements  of  which  are  imperative  want  of  move- 
ment, abnormal  rapidity  of  the  reactions,  and  impulsive 
character  of  the  acts. 

Maniacal  excitement  always  has  a  psychic  origin 
(Wernicke);  the  acts,  though  impulsive,  are  dependent 
upon  an  appreciable  cause  and  have  a  definite  purpose. 

This  excitement  often  assumes  the  aspect  of  morbid 
activity  which,  lacking  in  logical  sequence,  remains 
unproductive  when  it  does  not  become  harmful.  The 
maniac  every  instant  leaves  one  task  to  begin  another, 
or  undertakes  tasks  for  which  he  possesses  neither  the 
necessary  aptitude  nor  the  qualifications.  A  farmer, 
fifty  years  of  age  and  scarcely  able  to  read  or  write, 
wanted  to  undertake  the  study  of  Hebrew  ''to  unite 
the  Jews  and  the  Protestants." 

The  maniac  is  strongly  inclined  to  intrude  into  the 
affairs  of  others,  causing,  as  might  be  expected,  much 
trouble.  He  offers  his  ad\ice  and  assistance  to  every- 
body. In  the  asylum  he  accompanies  the  physician 
on  his  rounds,  makes  diagnoses,  and  prescribes  treat- 
ment. Often  he  tries  to  assist  the  nurses,  who  find  it 
very  difficult  to  moderate  his  zeal. 

In  the  more  marked  degrees  the  excitement  leads  the 
patient  to  many  eccentricities.  He  removes  his  cloth- 
ing, replaces  it;  executes  pirouettes  and  dangerous 
leaps;  sings  obscene  songs;  performs  grimaces  and 
contortions  for  the  amusement  of  his  spectators;  and 
frequently  annoys  others  in  a  thousand  ways. 

The  conversation  is  animated,  strewn  with  eccentric 
expressions,  strange  words  and  puns.     The  language  may 


298  MANUAL  OF  PSYCHIATRY. 

be  either  profane  and  obscene  or  marked  by  a  labored 
refinement.  The  tone  may  be  jocose  or  solemn,  accom- 
panied by  the  gestures  of  a  gamin  or,  on  the  contrary, 
by  those  of  a  commander  or  a  preacher.  There  is  often 
a  veritable  logorrhcea. 

The  writing  presents  analogous  characteristics.  Volu- 
bility and  proHxity  are  manifested  by  whole  pages 
scribbled  within  a  few  minutes.  The  lines  cross  each 
other  in  every  direction,  the  letters  are  large  in  size, 
and  capitals  and  flourishes  are  abundant.  Often  there 
is  maniacal  graphorrhosa,  analogous  to  the  maniacal 
logorrhcea  referred  to  above. 

The  discourse  is  conducted  at  random:  reflections 
upon  questions  of  transcendental  philosophy  as  well  as 
upon  those  of  dress  or  cooking;  slander  and  intimate 
confidences,  extravagant  projects,  and  erotic  proposals. 
The  maniac  conceals  nothing. 

Physical  symptoms.  —  We  find  in  mania  the  physical 
symptoms  which,  we  have  already  seen,  are  associated 
with  morbid  euphoria:  the  general  nutrition  and  the 
peripheral  circulation  are  active,  the  pulse  is  full  and 
rapid,  respiration  is  deep  and  accelerated,  the  appetite 
is  good,  and  the  weight  increases. 

Sleep  is  diminished,  occasionally  altogether  absent; 
but  in  s])ite  of  the  insomnia  the  patient  exi)eriences 
no  fatigue. 

Often  in  women  the  menses  are  suspended,  and 
their  return  announces  the  approach  of  recovery. 
When  they  persist  tlirough  the  attack  thoir  ai:>))earance 
is  lik(»ly  to  ])rovoke  a  recrudescence  of  excitement. 

Delusional  mania.  —  The  fundamental  symptoms  are 
the  same  as  those  of  simple  mania.     The  excitement 


MANIC  DEPRESSIVE  PSYCHOSES.  299 

may  be  more  marked  and  the  lucidity  perhaps  tran- 
sitorily disturbed. 

The  delusions  are  usually  mobile  and  consist  in  ideas 
of  grandeur. 

The  most  varied  delusions  follow  each  other,  modified 
every  instant  by  external  impressions.  The  patient 
assumes  all  the  titles  mentioned  to  him:  he  is  in  turn 
pope,  physician,  and  admiral.  Occasionally  the  delu- 
sions are  referred  to  the  past  and  take  the  form  of  pseudo- 
reminiscences:  a  shoemaker  pretended  to  have  directed 
an  expedition  to  the  North  Pole. 

The  patient  often  transforms  the  surroundings  in 
which  he  finds  himself.  A  maniac  called  the  head 
nurse  of  the  service  where  he  was  treated  the  chief  of 
his  military  station,  and  the  physician  the  prince  of 
Sagan. 

The  costume  corresponds  with  the  delusions:  the 
patients  clothe  themselves  in  fantastic  uniforms,  cover 
their  chests  with  decorations,  comb  their  hair  in  the 
style  of  Bonaparte,  etc. 

Sometimes  one  delusion  persists  and  remains  fixed 
during  the  entire  duration  of  the  attack  in  the  midst 
of  more  mobile  accessory  delusions:  a  modest  business 
agent  for  several  months  proclaimed  himself  to  be  the 
President  of  France,  and  referred  to  the  physicians  and 
nurses  as  his  "  grand  staff." 

The  maniac  never  has  absolute  faith  in  his  delusions. 
His  conviction  is  easily  shaken.  Often  even  he  himself 
only  half  believes  in  the  pompous  titles  that  he  gives 
himself;  his  delusions  are  a  sort  of  pleasantry  with 
which  he  amuses  himself  and  with  which  he  mystifies 
those  about  him. 


300  MANUAL  OF  PSYCHIATRY. 

Some  ideas  of  persecution,  mostly  bearing  upon  the 
deprivation  of  liberty,  may  occur  in  addition  to  the 
ideas  of  grandeur.  In  some  cases  even  hypochondriacal 
ideas  may  occur.  The  patient  declares  that  he  is 
afflicted  with  a  grave  disease,  but  that  he  will  cure  him- 
self "  by  taking  a  trip  to  London  "  or  by  having  an 
operation  done  by  "  the  greatest  specialists  of  Paris 
and  America." 

Hallucinations  are  rare  and  fleeting.  On  the  other 
hand,  illusions  are  frequent  and  lasting;  they  often 
assume  the  form  of  mistakes  of  identity :  the  patient  is 
apt  to  believe  himself  surrounded  by  his  acquaintances 
and  by  familiar  objects. 

In  grave  forms,  during  the  excited  paroxysms,  the 
consciousness  at  times  undergoes  a  certain  degree  of 
clouding  and  the  period  of  illness  leaves  but  a  very 
vague  impression,  or  none  at  all,  upon  the  memory. 

The  following  case  is  a  good  example  of  delusional 
mania. 

Gabriolle  L.,  fifty-two  years  old,  housewife.  Family  history 
unknown.  The  patient  has  always  been  impressionable  and  lively; 
intelligence  normal.  She  had  five  previous  attacks  of  mania,  the 
first  at  the  age  of  nineteen;   all  terminated  in  recovery. 

The  present  attack  began  with  ratnbling  speech,  assaults  upon 
others,  and  a  tendency  to  alcoholic  excesses;  tlie  patient,  though 
usually  temperate,  began  to  drink  to  intoxication.  She  was  taken 
to  the  Clermont  Asylum  where  Dr.  Boiteaux  issued  the  following 
certificate  of  lunacy:  "Condition  of  acute  mania  with  extreme 
disorder  of  ideation,  speecli,  antl  conduct.  Illusions  of  tlie  senses. 
Obscene  actions.  Ideas  of  grandeur:  owns  millions,  heavens  and 
earth.     Excited,  difficult  to  control." 

On  Fel)ruary  '2ii,  VM)l,  one  month  after  the  patient's  admission 
to  the  asylum,  examination  was  as  follows:  Medium  stature,  strong 
constitution,  slight  obesity,  skin  flushed,  voice  loud,  gestures  lively, 
clothing   disarranged,    hair   ilown   over  the   shoulders.     From   the 


MANIC   DEPRESSIVE  PSYCHOSES.  301 

beginning  the  patient  showed  extreme  familiarity.  She  offered 
her  arm  to  the  physician,  whom  she  took  to  be  the  husband  of  the 
head  nurse,  and  laughingly  asked  the  latter  if  she  was  not  jealous. 
She  was  well  oriented  as  to  place;  she  knew  that  she  was  at  the 
Insane  Asylum  at  Clermont  where  she  had  already  been  five  times 
before.  Her  orientation  of  time  was  somewhat  inaccurate:  she 
said  the  year  was  1904,  that  it  was  the  spring  of  the  year,  and  gave 
the  date  as  March  25  (actual  date  February  25,  1904) ;  on  being 
asked  to  think  a  while  and  make  sure  of  the  date,  she  said:  "Why, 
of  course  it  is  March,  a  few  days  ago  we  had  a  holiday,  that  was 
Mid-Lent."  (She  was  evidently  referring  to  Shrove  Tuesday.) 
Later  other  ideas  appeared  and  it  became  impossible  to  prevail 
upon  the  patient  to  reflect  properly  before  speaking.  She  had  a 
certain  realization  of  her  condition:  she  said  she  felt  odd,  "at 
times  driven  to  play  all  sorts  of  silly  pranks."  She  was  very  obe- 
dient, and  always  started  out  with  remarkable  eagerness  to  carry 
out  any  order  that  might  be  given  her.  But  her  extremely  mobile 
attention  caused  her  to  be  each  instant  distracted  from  the  object 
to  be  attained.  She  was  asked  to  write  a  letter:  "Why,  certainly! 
To  whom?"  To  whomever  you  wish.  "Very  well,  to  the  Presi- 
dent of  the  Republic?  To  the  Minister  of  War?  No,  I  shall  write 
to  my  husband."  Then  she  began  to  write:  To  Mr.  L.,  Gardener 
in  C.  .  .  .  Then  turning  again  to  the  physician:  "Because,  you 
know,  we  have  been  living  in  C.  .  .  .  for  the  past  eighteen  years. 
I  have  a  house  there.  The  hospital  at  C.  .  .  .  belongs  to  me.  I 
know  Sister  Antoinette  there.  They  wanted  me  to  disguise  myself 
as  a  Sister,  but  my  husband  wouldn't  have  it.  He  adores  me,  my 
husband  does!"  She  was  again  asked  to  write,  which  she  did, 
jabbering  all  the  time  and  reading  aloud  everything  she  wrote. 
Every  moment  her  attention  kept  getting  distracted  by  the  con- 
versation of  the  persons  in  the  room,  although  they  spoke  in  a  low 
voice  and  upon  matters  which  did  not  concern  the  patient.  They 
spoke,  in  fact,  about  another  patient  who  helped  the  nurses  with 
the  service  in  the  dining-room.  "Good  gracious!"  exclaimed  the 
patient,  interrupting  her  writing  and  bursting  out  with  laughter, 
"that  woman  is  pretty  stingy  with  her  bread!  One  would  think 
she  was  paying  for  it!  It  was  I  that  gave  her  the  money  to  buy  it 
with!"  When  asked  again  to  continue  her  letter  she  mllingly 
resumed  her  writing.  A  minute  later  they  spoke  about  another 
patient,  and  someone  made  the  remark,  "She  does  not  sleep." 
This  started  the  patient  again:  "Who,  I?  I  don't  sleep?  Why,  I 
sleep  hke  a  dormouse!"     It  is  to  be  noted  that  she  wrote  slowly, 


302  MANUAL  OF  PSYCHIATRY. 

seeking  her  words.  Having  had  but  little  schooling,  writing  in  her 
case  did  not  develop  into  an  automatic  function.  She  threw  down 
her  pen  after  having  written  a  few  disconnected  lines.  She  was 
then  given  a  paper  and  asked  to  read  aloud  one  of  the  news  items. 
Her  attention  was  at  once  attracted  by  a  picture  below  the  news 
item  and  she  exclaimed,  pointing  to  it:  "Here  is  a  pretty  woman! 
She  resembles  Mrs.  P."  She  was  again  urged  to  read.  She  read 
the  first  Une  with  difficulty,  owing  to  her  poor  vision,  and  continued 
to  read  on  the  same  level  in  the  next  column.  Again  the  above 
news  item  was  pointed  out  to  her.  It  was  about  some  poor  old 
man.  The  patient  at  once  stopped  her  reading:  "This  is  a  jolly 
story!  The  poor  old  man!  and  the  veterans!  I  visited  them  once, 
also  the  buildings  for  arts  and  for  commerce."  With  a  good  deal 
of  urging  she  was  finally  induced  to  read  the  entire  news  item; 
but  it  made  very  little  impression  on  her  mind;  a  quarter  of  an 
hour  later  she  was  unable  to  tell  even  briefly  what  she  had  read, 
declaring  simply  that  it  was  something  about  an  old  man.  "It 
is  very  sad,"  she  added,  "sad  and  humiliating.  Thinking  of  death 
always  distresses  me,  but  I  am  very  fond  of  flowers.  My  husband 
is  a  gardener  in  C.  .  .  .  He  buys  his  seeds  from  Vilmorin,  also 
his  tobacco."  Numerous  unsystematized  grandiose  delusions:  she  is 
a  midwife,  she  studied  for  forty  years;  she  is  a  millionairess,  owns 
mansions;  her  husband  has  invented  perpetual  motion,  made  the 
model  with  nothing  but  his  knife;  he  has  also  invented  a  method 
for  making  cheese  boxes  out  of  the  stalks  of  rye,  which  he  will  sell 
for  ten  cents  apiece.  He  is  related  to  the  king  of  Italy  and  is 
of  noble  descent.  In  her  delusions  the  patient  showed  marked 
suggestibility:  she  was  asked,  "Have  you  ever  been  on  the 
stage?  " — "Why,  yes,  I  played  in  Tlie  Chimes  of  Normandy."  Here 
she  began  to  sing:  "Will  you  look  this  way,  will  you  look  that 
way?"  Her  children  are  also  actors.  She  played  with  them  at 
the  Castle  Theatre,  also  with  Sarah  Bernhardt.  Here  her  eye 
fell  upon  the  word  "Minister"  printed  in  large  letters  in  the  paper; 
she  said:  "My  husband  has  not  yet  been  made  Minister,  but  with 
his  ability  he  will  not  have  to  wait  long."  She  has  no  hallucina- 
tions, but  numerous  illusions,  especially  those  of  vision.  She 
thinks  she  knows  all  those  about  her.  One  nurse  is  her  cousin, 
another  is  her  neighbor  living  across  the  street.  Her  motor  excite- 
ment is  very  marked.  The  patient  tries  to  do  every  kind  of  work; 
she  makes  a  few  sweeps  with  the  broom,  then  suddenly  rushes  to 
assist  a  nurse  carrying  a  pail  of  water,  then  leaves  the  nurse  with 
her  pail  of  water  to  go  and  make  peace  between  two  quarreling 


MANIC  DEPRESSIVE  PSYCHOSES.  303 

patients.  Without  any  intention  of  malice,  she  has  frequent  alter- 
cations with  other  patients  who  are  annoyed  by  her  screams,  her 
songs,  and  her  wild  pranks.  She  picks  up  the  most  varied  objects 
and  accumulates  them  in  her  clothes:  scraps  of  paper,  bits  of 
glass,  wood,  and  metal,  pieces  of  bread  and  of  cheese.  She  her- 
self laughs  when  an  inventory  is  taken  of  all  this  rubbish,  and 
makes  no  objection  to  its  being  taken  away  from  her. 

No  noteworthy  disorders  in  her  general  condition.  She  eats  at 
all  times,  abundantly  and  gluttonously.  Sleep  somewhat  dis- 
turbed: she  passes  part  of  the  night  wandering  about  the  dormi- 
tory, singing  and  jabbering. 

Confused  mania.  —  Clouding  of  consciousness  is  here 
permanent.  The  attack  begins  suddenly  or  after  a 
short  prodromal  period,  characterized  from  the  beginning 
by  complete  disorientation,  very  great  excitement,  and 
totally  incoherent  delusions.  Numerous  hallucinations 
always  accompany  the  delusions.  The  form  of  the 
delusions  is  very  variable:  in  confused  mania  are  often 
encountered  ideas  of  grandeur,  of  persecution,  and 
occasionally,  by  way  of  an  accidental  episode,  some 
melancholy  delusions. 

Even  when  the  grandiose  ideas  predominate  euphoria 
is  very  frequently  absent.  The  cause  of  this  anomaly 
probably  exists  in  the  purely  automatic  character  of  all 
the  psychic  manifestations.  To  provoke  a  sense  of 
pleasure  the  acti\'ity  must  be  conscious,  that  is  to  say, 
accompanied  by  a  voluntary  effort,  no  matter  how 
slight;  whereas  in  confused  mania  fragmentation  of  the 
personality  is  such  that  the  flight  of  ideas  is  effected 
with  extreme  facility ;  the  effort  is  absent  and  with  it  the 
euphoria. 

The  patient  loses  weight,  the  features  become  drawn 
out,  the  pulse  grows  small  and  depressible.  The  inten- 
Bity  of  the  excitement  permits  of  no  regular  alimentation. 


304  MANUAL  OF  PSYCHIATRY. 

Filthy  tendencies  are  frequent:  unless  watched  con- 
stantly the  patient  is  apt  to  smear  the  walls,  his  bed, 
his  clothing,  and  his  own  body  with'  faeces.  Some  will 
even  eat  faeces. 

The  attack  may  terminate  in  death,  either  from 
general  exhaustion  or  from  some  intercurrent  compli- 
cation: pneumonia,  suppuration  occasioned  by  trauma- 
tism, etc. 

General  course,  duration,  and  prognosis  of  a  maniacal 
attack.  —  The  course  of  mania  is  capricious.  In  a  general 
way  it  may  be  represented  by  a  curve  which  at  first 
ascends,  then  remains  horizontal  for  a  longer  or  shorter 
time,  and  finally  gradually  descends.  But  this  curve, 
far  from  being  regular,  is  interrupted  by  oscillations 
indicating  either  sudden  exacerbations  or  attenuations 
of  the  symptoms,  or  even  true  remissions  the  duration 
of  which  may  vary  from  several  minutes  to  several 
days. 

The  progress  of  the  attack  may  also  be  interrupted 
by  phenomena  of  dei)ression  which  are  sometimes  quite 
marked,  though  very  brief  in  duration.  As  we  shall 
see  later  on,  this  fact  contributes  to  the  proof  of  the 
homogeneity  of  manic  depressive  insanity. 

The  (hmition  of  the  attack,  whatc\'or  its  form,  cannot 
be  predicted.  Some  attacks  terminate  in  a  few  hours, 
deserving  a  jolace  among  the  transitory  insanities^  others 
continue  for  several  years. 

The  jirognosis,  leaving  out  the  cases  in  wliicli  life  is 
endangered  by  the  intensity  of  the  excitement  or  by 
some  complication,  is  favorable  as  to  the  termination 
of  the  attack  itself.  Recovery  with  restitutio  ad  inte- 
grum is  the  rule. 


MANIC  DEPRESSIVE  PSYCHOSES.  305 

In  some  cases  recovery  has  been  observed  to  occur 
following  some  acute  somatic  disease. 

Treatment.  —  Rest  in  bed  in  these  cases  performs 
miracles.  It  is  well  accepted  and  easily  instituted. 
Unfortunately  it  is  not  possible  at  present  to  say  whether 
or  not  it  actually  shortens  the  duration  of  the  disease. 

§  2.  Depressed  Type. 

The  fundamental  symptoms  of  the  depressed  type 
of  manic  depressive  insanity  are: 

Psychic  inhibition; 

A  painful  emotional  state  associated  with  indifference; 

Aboulia. 

As  in  the  case  of  mania,  we  distinguish  here  three 
forms:    simple,    delusional,    and    stuporous    depression. 

Simple  depression.  —  Onset.  —  Usually  insidious,  pre- 
ceded by  ill-defined  prodromata,  such  as  general  tired 
feeling,  insomnia,  anorexia,  discouragement. 

The  external  aspect  of  the  patient  is  one  of  sadness, 
listlessness,  and  indifference.  The  features  are  drawn 
out,  the  head  bowed  down  upon  the  chest,  the  arms 
hanging  inertly  at  the  sides  or  resting  upon  the  knees. 
The  general  bearing  is  slouchy. 

Intellectual  disorders.  —  The  psychic  inhibition  brings 
about  very  marked  weakening  of  attention  and  con- 
siderable sluggishness  of  the  association  of  ideas.  All 
intellectual  exertion,  such  as  the  narration  of  an  event 
well  known  to  the  patient  or  a  small  calculation,  is 
impossible  or  can  be  accomplished  only  after  repeated 
and  painful  efforts.  Though  lucidity  is  intact,  the 
perceptions  are  incomplete,  uncertain,  and  often  inac- 


306  MANUAL  OF  PSYCHIATRY. 

curate.  Everything  appears  to  the  patient  strange  or 
unrecognizable:  persons,  objects,  and  even  his  own 
body.  Here  we  have  a  condition  bordering  upon  a 
delusional  state.  Another  step  and  we  have  illusions 
and  hypochondriacal  ideas. 

The  disorders  of  judgment  are  less  marked  than  in 
mania.  Tlie  patient  is  quite  frecjuently  conscious  of 
his  condition  to  some  extent.  He  feels  that  he  is 
changed,  ill,  and  it  seems  to  him  that  his  mind  is 
paralyzed. 

Affective  disorders.  —  The  mood  is  sad,  gloomy,  pessi- 
mistic. The  patient  emits  monotonous  groans.  While 
the  maniac  brings  disorder  into  a  service  of  an  asylum, 
the  melancholiac  brings  depression  and  gloom. 

The  psychical  anasthesia  is  always  very  marked,  and 
sometimes  the  patient  is  conscious  of  it.  He  com- 
plains of  having  become  indifferent  towards  every- 
thing, of  experiencing  no  affection. 

Upon  this  general  state  of  depression  and  sadness 
may  be  engrafted  a  spell  of  anxiety,  usually  transient. 
In  no  case,  however,  is  the  psychic  pain  so  intense  as 
in  affective  melancholia.  The  depressed  phases  of 
manic  depressive  insanity  correspond  to  passive  de- 
pression. 

Disorders  of  the  reactions.  — These  all  result  from  the 
marked  aboulia  present  in  such  cases,  which  is,  in  its 
turn,  a  manifestation  of  the  psychic  paralysis. 

The  execution  of  the  simplest  act  necessitates  an  effort 
so  great  at  times  that  the  patient  gives  up  the  attempt. 
As  in  the  case  of  the  psychic  indifference,  this  symptom 
may  be  a  conscious  one. 

Cbmbined   with   insufficiency   of   perception,   aboulia 


MANIC  DEPRESSIVE  PSYCHOSES.  307 

brings    about    doubt.    The    patient    lives    in    constant 
indecision  and  uncertainty. 

Conversation  with  the  patient  is  most  unsatisfactory. 
Often,  in  spite  of  all  persistence,  the  patient  remains 
mute  or  responds  by  an  unintelligible  murmur  or 
whispering.  The  mental  synthesis  necessary  for  an 
elaboration  of  a  response  is  impossible  for  him.  In  the 
milder  cases,  to  some  very  simple  questions  repeated 
several  times  brief  answers  are  obtained. 

The  voice  is  scarcely  audible,  the  speech  is  indistinct. 
The  same  words  are  constantly  reiterated,  expressing 
doubt,  indecision,  sadness:  "  What  is  this?. . .  What  is 
going  to  happen?. . .  This  is  frightful." 

The  writing  is  slow;  letters  are  poorly  formed,  small, 
disconnected. 

Physical  symptoms.  —  These  have  already  been  de- 
scribed in  connection  with  morbid  depression.  I  shall 
review  them  briefly. 

The  peripheral  circulation  is  sluggish,  the  extremities 
cold  and  cyanotic.  The  pulse  is  small,  of  low  tension, 
sometimes  slowed.  The  heart-sounds  are  muffled. 
The  temperature  may  be  subnormal. 

The  coated  tongue,  fetid  breath,  a  sense  of  weight, 
in  the  stomach,  constipation,  and  anorexia  reveal  a 
poor  state  of  the  digestive  functions. 

Loss  of  weight  is  a  constant  phenomenon.  The 
return  to  the  normal  weight  always  indicates  the  end 
of  the  attack. 

Sleep  is  diminished,  unrefreshing,  disturbed  by  night- 
mares. 

Often  the  patient  complains  of  headache  and  of  vagv^ 
pains  in  the  limbs. 


308  MANUAL  OF  PSYCHIATRY. 

The  cutaneous  sensibility  is  blunted. 

The  tendon  reflexes  are  often  diminished,  sometimes 
abolished. 

Delusional  depression.  —  Always  secondary  to  the 
emotional  state,  the  delusions  are  preceded  by  a  longer 
or  shorter  period  of  simple  depression. 

They  jiresent  the  usual  characters  of  depressive  ideas 
and  assume  the  most  varied  forms:  hypochondriacal 
ideas,  ideas  of  humility,  of  self-accusation,  or  of  ruin, 
fear  of  terrible  punishment. 

As  in  affective  melancholia,  the  morbid  idea  may  oc- 
cur at  first  in  the  shape  of  an  imperative  idea.  The 
mind  realizes  it  is  false  and  tries  to  reject  it.  After 
a  more  or  less  prolonged  struggle,  the  mind  yields: 
the  imperative  idea  becomes'a/xed  idea,  and  a  delusional 
state  is  established. 

Occasionally  these  delusions  are  quite  absurd  and 
resemble  those  of  dementia.  In  other  cases  they  are 
associated  \\ith  ideas  of  persecution  and  become  sys- 
tematized to  a  certain  extent,  constituting  a  systema- 
tized delusional  state  of  self-accusation  or  of  persecution, 
as  the  case  may  be. 

(Hallucinations  are  rare.     The  least  exceptional  are 
those  of  \ision. 

Illusions,  though  less  numerous  than  in  mania,  are, 
however,  quite  freciuent.  Following  the  general  rule, 
the  psycho-sensory  disorders  are  an  expression  of  the 
delusional  preoccupations. 

Lucid  ill/  may  be  transitorily  affected.  The  usual 
inertia  is  sometimes  effaced  and  replaced  })y  a  certain 
degree  of  ex('it(>nient.  In  other  cases  it  becomes,  on  the 
contrary',  more  marked,  giving  rise  to  transient  stupor. 


MANIC   DEPRESSIVE  PSYCHOSES.  309 

Depression  with  stupor.  —  This  form  rarely  be^ns 
as  such;  it  is  usually  preceded  by  simple  or  delusional 
depression.  — 

The  characteristic  trait  here  is  .complete  inertia, 
associated  with  absolute  indifference  to  all  external 
impressions.  The  physiognomy  is  stupid,  sometimes 
expressing  fear.  ^ 

The  usual  physical  symptoms  of  depression  are  here 
very  pronounced,     i- 

^  Almost   always   the   patient   becomes   negligent  and 
fdiliy,  wetting  and  soiling  his  bed. 

In  some  cases  may  be  observed  a  tendency  to  cata- 
leptoid  attitudes. 

The  stupor  may  have  one  of  two  different  origins: 

(1)  The  psychic  inhibition  reaching  an  extreme 
degree  of  intensity  suppresses  all  conscious  and  volun- 
taiy  intellectual  activity.  The  indifference  is  complete, 
the  psychic  pain,  on  the  contrary,  becoming  nil,  in 
fact  inhibition  is  never  perceived  as  a  painful  phe- 
nomenon unless  the  mind  seeks  to  overcome  it;  in  the 
stupor  the  arrest  of  psychic  activity  is  so  complete  that 
the  patient  makes  no  attempt  to  react. 

(2)  The  patient's  mind  is  preoccupied  by  intense, 
frightful  delusions.  There  is  an  endless  succession  of 
terrifying  hallucinations  analogous  to  those  of  epileptic 
delirium.  The  patient  is  in  a  frightful  nightmare  which 
completely  absorbs  him,  rendering  him  insensible  to 
impressions  of  the  external  world. 

Course,  duration,  and  prognosis  of  the  depressed  type 
of  manic  depressive  insanity.  —  As  in  mania,  the  course 
is  irregular,  interrupted  by  temporary  remissions  and 
exacerbations.     The  duration  varies  \ntliin  verv  wide 


310  MANUAL  OF  PSYCHIATRY. 

limits,  from  a  few  days  to  several  months  or  even  years; 
the  prognosis  is  always  favorable  for  recovery  from  the 
attack,  except  in  cases  with  grave  somatic  complications. 
Physical  improvement,  especially  increase  in  weight, 
usually  indicates  the  approach  of  recovery. 
The  treatment  consists  in: 

(1)  Sustaining  the  strength  of  the  patient  by  rest, 
especially  rest  in  bed,  and  by  a  plentiful  and  nutritious 
diet; 

(2)  Careful  watching  to  prevent  suicide; 

(3)  Calming  agitation,  when  present,  by  the  usual 
procedures; 

(4)  Combating  the  gastric  disorders  and  the  phenom- 
ena of  autointoxication  that  are  so  frequent  in  states 
of  depression. 

Psychic  treatment  in  the  form  of  suggestion,  moderate 
physical  and  intellectual  labor,  etc.,  is  of  great  service 
during  convalescence,  but  is  absolutely  contraindicated 
during  the  entire  acute  period  of  the  disease. 

^^'^'       §3.  Mixed  Types. 

Attacks  of  mixed  form,  properly  so  called.  —  Kraepe- 
lin  has  thrown  light  upon  the  true  nature  of  these  cases, 
which  are  more  frequent  than  is  generally  supposed  and 
in  which  the  symptoms  of  excitement  and  of  depression 
appear  in  tlie  same  ])atient  at  the  same  time. 

In  one  group  of  easels  the  usual  signs  of  depression 
are  associated  with  extreme  mobility  of  attention 
and  veritable  flight  of  id(>as.  Tlie  patients  complain 
that  the  direction  of  their  thoughts  escapes  them. 
"My   head   always   wanders,"    said   one   such   patient: 


MANIC  DEPRESSIVE  PSYCHOSES.  311 

"  I  cannot  fix  my  attention  upon  anything."  Occa- 
sionally there  is  melancholic  logorrhoea.  Many  de- 
pressed patients  show-a  surprising  prolixity  and  harass 
those  about  them  by  unceasing  incoherent  lamentations 
about  their  unhappy  lives.  ^ 

In  a  second  group  of  cases  the  disease  presents  itself 
with  the  characteristics  of  maniacal  stupor  (Kraepelin). 
The  psychic  paralysis  is  associated  with  more  or  less 
pronounced  excitement:  the  patient  is  constantly 
mo\ing,  disarranges  his  bed,  tears  his  clothes,  soils  the 
walls  of  his  room,  and  at  the  same  time  shows  such 
complete  intellectual  obtuseness  that  even  the  simplest 
questions  put  to  him  remain  unanswered. 

Finally,  in  a  third  group,  inhibition  is  less  pronounced, 
and  the  elated  mood  of  mania  is  replaced  by  an  uneasy, 
gloomy,  irritable  one,  the  basis  of  which  is  sadness,  like 
in  the  depressed  type. 

The  mixed  type  sometimes  persists  through  the  entire 
duration  of  the  attack.  !More  frequently  it  is  met  with 
in  the  transition-periods  of  circular  insanity,  where  the 
patient  wavers,  so  to  speak,  between  excitement  and 
depression. 

Attacks  of  double  form.  —  Each  attack  is  here  consti- 
tuted by  tivo  periods:  a  period  of  depression  and  a 
period  of  excitement.  It  usually  begins  with  the 
depression. 

The  transition  from  depression  to  excitement  occurs 
either  suddenly,  —  a  patient  goes  to  bed  a  melancholiac 
and  rises  the  next  morning  a  maniac,  —  or  gradually, 
with  an  intervening  period  of  the  mixed  form  of  manic 
depressive  insanity,  as  mentioned  above.     The  psycho- 

*  Kraepelin.     Loc.  cit.,  p.  b-^b. 


312  MANUAL  OF  PSYCHIATRY. 

motor  inhibition  gradually  becomes  less  prominent  and 
is  replaced  by  excitement;  flight  of  ideas  and  logorrhtca 
appear.  Finally  the  sadness  disappears  and  maniacal 
elation  replaces  it. 

When  a  maniac  falls  into  depression  the  same  transi- 
tion occurs  inversely. 

The  treatment  of  each  phase  comprises  the  same 
indications  as  for  attacks  of  simple  depression  and 
of  mania  respectively. 

§  4.  General  Course.  —  Prognosis  of  Manic  Depres- 
sive Insanity.  —  General  Considerations.  — 
Treatment. 

Attacks  of  manic  depressive  insanity  present  a 
very  marked  tendency  to  recur.  According  to  the 
particular  forms  assumed  by  the  successive  attacks, 
several  types  of  manic  depressive  insanity  are  dis- 
tinguished. 

(A)  Periodic  insanities : 
(a)  Recurrent    mania; 

(6)  Recurrent    melancholia. 

(B)  Alternating  insanity. 

(C)  Insanity  of  double  form. 
(I))  Circular  insanity. 

(E)  Irregular    forms. 

(A)  Periodic  insanities.  —  (a)  Recurrent  mania. — The 
attacks  are  always  of  the  maniacal  type  and  are  sepa- 
rated from  each  oilier  by  normal  periods.  The  number 
of  attacks  and  the  duration  of  the  normal  periods  vary 
greatly.  Some  patients  have  Init  two  or  three  attacks 
(luring  their  lifetime;  it  is  altogether  ex('ei)tional  for  an 
individual  to  have  but   one  attack,  at  least  if  his  life 


MANIC  DEPRESSIVE  PSYCHOSES.  313 

is  a  long  one.     In  all  likelihood  non-recurring  mania 
does  not  exist. 

In  other  cases  the  attacks  follow  each  other  at  brief 
intervals  and  with  a  certain  regularity. 

Excitement  Excitearent  Excitement 

/^\  / \  / \ 

Normal      / \  Normal/ \Normal/ \       Normal 

State  State  State  State 

SCHEME  I.     RECURRENT  MANIA. 

(6)  Recurrent  melancholia.  — Less  frequent  than  the 
preceding,  this  form  is,  so  to  speak,  its  counterpart. 
What  has  been  said  about  recurrent  mania  is  applicable 
to  recurrent  depression. 

Normal Normal NoTmal Nbrmal 

State       V  /State  \  X  State  \  "7     State 

Depression  Depression  Depiession 

SCHEME  II.     RECURRENT  MELANCHOLIA 

(B)  Alternating  insanity.  —  Attacks  of  mania  and 
those  of  depression  alternate  and  are  separated  from 
each  other  by  normal  intervals. 


Normal 


jatciteniem  Jixcitcmena 

ly^ \  Normal  Normal  / \  Normal 

Y  /State  BtateX  T" 


State 

Depression  Depression 

SCHEME  l!l.     ALTERNATING  INSANITY. 

(C)  Insanity  of  double  form.  —  Each  attack  consists 
of  a  period  of  depression  and  one  of  excitement;  the 
attacks  are  separated  from  each  other  by  normal 
intervals. 

t  Exe.itgmcnt  Excitoment 

Nbrmal 


DepressioD.  Depression  O^ccssion 

SGHEME"iV.     INSANITY  OF  DOUBLE  FORM. 


314  MANUAL  OF  PSYCHIATRY. 

(D)  Circular  insanity.  —  Attacks  of  tlouble  form  follow 
each  other  without  interruption. 

■Ercltcnicnt  Excitemeril  Eiccflemenl! 


Depression  Depression.  Depression  Depression 

SCHEME  V.    CIRCULAR  INSANITY. 

(E)  Irregular  forms.  —  These  are  the  most  frequent. 
The  attacks  follow  each  other  without  order  or  regu- 
larity, assuming  at  random  the  depressed,  manic,  or 
mixed  form. 

Finally,  one  may  observe  the  periodic,  circular,  and 
irregular  forms  combine  in  a  very  complex  manner,  so 
that,  for  instance,  a  patient  with  circular  insanity  be- 
comes a  periodic  maniac  for  a  time,  or  a  patient  whose 
previous  attacks  have  all  been  of  the  manic  type  presents 
an  attack  of  depression. 

It  is  quite  frequent,  though  not  constant,  to  see 
attacks  of  the  same  type  present  each  time  the  same 
aspect:  a  manic  attack  resembles  previous  ones  in  the 
same  patient,  and  it  is  very  probable  that  the  future 
manic  attacks  will  present  the  same  features. 

The  general  prognosis  of  the  disease  is  not  favorable. 
The  attacks  have  in  some  cases  a  tendency  to  come 
closer  together,  so  that  the  normal  intervals  be- 
come gradually  shorter  and  shorter  until  they  are 
either  totally  wanting  or  almost  so. 

Manic  depressive  insanity  is  a  common  disease. 
According  to  Kracpelin  it  represents  about  15%  of 
all  asylum  admissions. 

The  causes  are  not  fully  known;  the  essential 
feature  in  the  etiology  seems  to  be  a  constitutional 


MANIC  DEPRESSIVE  PSYCHOSES.  315 

predisposition  which  is  beUeved  to  be  inherited. 
Kraepehn  has  found  neuropathic  heredity  in  80%  of 
his  cases;  the  heredity  is  often  similar. 

The  special  predisposition  to  have  attacks  of 
manic  depressive  insanity  seems  to  be  observed  with 
particular  frequency  in  persons  of  certain  fairly  well- 
defined  mental  make-up;  such  make-up  is  char- 
acterized either  by  a  sort  of  constitutional  pessimism, 
gloomy  or  worrisome  disposition,  or,  on  the  contrary, 
by  a  happy,  exuberant,  demonstrative  temperament, 
or,  finally,  by  emotional  instability  consisting  of 
exaggerated  reactions  to  situations  by  despair,  dis- 
couragement, or  by  premature  and  unwarranted  dis- 
play of  triumph  and  hopefulness,  as  the  case  may 
be.  This  was  pointed  out  by  Hoch^  who  has  empha- 
sized particularly  the  contrast  which  such  person- 
alities present  to  that  type  of  personality  —  the 
''shut-in  personaUty" — which  he  has  defined  as 
being  particularly  prone  to  develop  dementia  prse- 
cox.?  In  a  more  recent  study  Reiss  has  arrived  at 
similar  conclusions,  as  may  be  seen  from  the  following 
quotation:^  ''Upon  a  survey  of  the  whole  material 
which  has  been  at  my  disposal,  we  find  as  a  general 
fact  that  in  cases  of  happy  disposition  manic  states, 
while  in  those  of  pronounced  depressive  disposition 
the  sad  melancholy  states  predominate." 

The  age  at  which  the  first  attack  occurs  is  not  con- 


1  Joum.  of  Nerv.  and  Ment.  Dis.,  Apr.,  1909. 

2  See  p.  284. 

^  Eduard  Reiss.  KonstitutioneUe  Verstimmung  und  manisch' 
depressives  Irresein.  Zeitschr.  f.  die  gesamte  Neurol,  u.  Psychiatrie, 
Vol.  II,  p.  600,  1910. 


316  MANUAL  OF  PSYCHIATRY. 

stant.  In  most  cases  it  is  before  the  twenty-fifth 
year,  in  some  before  the  tenth,  and  in  others  after  the 
fiftieth.  Quite  frequently  in  women  the  disease  ap- 
pears with  the  onset  of  menstruation  or  with  the 
first  pregnancy. 

Diagnosis.  —  The  principal  elements  of  diagnosis 
are:  psychic  paralysis  associated  with  the  special 
symptoms  of  exaltation  of  the  mental  automatism, 
which  have  already  been  described;  absence  of  real 
intellectual  enfeeblement ;  recurrency  of  the  attacks 
with  restitutio  ad  integrum  after  each. 

We  differentiate: 

General  paresis  by  the  pathognomonic  intellectual 
enfeeblement,  a  certain  degree  of  which  persists  even 
during  the  remissions ;  and  by  the  equally  pathogno- 
monic physical  signs; 

Involutional  melancholia  by  the  intense  and  per- 
sistent psychic  pain,  which  is  much  more  marked 
than  in  the  depressed  form  of  manic  depressive 
insanity; 

Acute  confusional  insanity  by  its  special  etiology, 
and  by  the  much  more  marked  disorientation; 

Delirium  tremens  by  its  specific  hallucinations; 

Dementia  prcecox  by  the  rapid  and  pronounced 
diminution  of  affectivity,  by  the  catatonic  phenom- 
ena which  are  so  frequent  in  such  cases,  and  by  th(» 
absence  of  flight  of  ideas  even  in  those  cases  which 
closely  resemble  mania. 

Homogeneity  of  manic  depressive  insanity.  —  Funda- 
mental symptoms.  —  The  conception  of  manic  de- 
pressive insanity  is  due  to  Kraepelin  and  constitutes 
one    of    the    most    important    recent    advances    in 


MANIC  DEPRESSIVE  PSYCHOSES.  317 

psychiatry.  Although  the  grouping  of  such  ap- 
parently different  and  even  opposite  pathological 
states  as  melancholic  depression  and  mania  may 
appear  unreasonable  on  superficial  consideration,  its 
legitimacy  is  nevertheless  incontestable  and  is  based 
upon  two  principal  arguments: 

(1)  The  existence  of  certain,  fundamental  symptoms 
common  to  all  forms,  manic,  depressed,  or  mixed. 

(2)  The  alternation,  regular  or  not,  as  the  case  may 
be,  of  the  phenomena  of  excitement  and  of  depression 
in  the  same  subject. 

(1)  Fundamental  symptoms.  —  The  symptoms  of 
manic  depressive  insanity  can  be  readily  divided  into 
two  groups. 

The  first  group  comprises  all  the  morbid  phenomena 
dependent  upon  psychic  paralysis,  namely:  (a)  weak- 
ening of  attention;  (6)  sluggish  formation  of  asso- 
ciations of  ideas;  (c)  insufficiency  of  perception; 
(d)  pathological  indifference. 

These  symptoms  of  psychic  paralysis  are  es- 
pecially prominent  in  the  depressed  type.  But  in 
mania,  though  usually  marked  by  phenomena  of  ex- 
aggeration of  the  mental  automatism  (flight  of  ideas, 
motor  excitement),  they  are,  nevertheless,  also 
present,  as  can  be  readily  shown  by  a  careful  ex- 
amination. 

Let  us  consider  these  symptoms  individually. 

(a)  Weakening  of  attention.  —  Abnormal  mobifity 
of  attention  is  one  of  the  fundamental  symptoms 
of  mania.  Yet,  as  shown  in  the  first  part  of  the 
book,  this  is  but  a  manifestation  of  weakening  of 
attention. 


318  MANUAL  OF  PSYCHIATRY. 

(b)  Sluggish  formation  of  associations  of  ideas.  — 
Kraepelin  ^  and  his  pupils  have  shown  by  means  of 
psychometry  that  the  acceleration  of  mental  proc- 
esses in  mania  affects  only  the  automatic  processes, 
voluntary'  associations  of  ideas  being  actually  re- 
tarded, just  as  they  are  in  the  depressed  states. 

(c)  Insufficiency  of  perception.  —  Perception  of  the 
external  world  is  inaccurate  in  depression  as  well 
as  in  mania;  but  while  in  the  former  case  the  per- 
ceptions are  often  incomplete  and  are  manifested 
cUnically  by  uncertainty,  in  the  latter  case  automatic 
associations  occur  in  the  place  of  missing  normal 
ones  and  give  rise  to  false  perceptions  or  illusions. 
Neither  the  melancholiac  nor  the  maniac  perceives 
the  phenomena  of  the  external  world  in  their  true 
aspect,  but  the  one  remains  in  doubt  while  the  other 
affirms  errors. 

(d)  Pathological  indifference  also  clearly  exists  in 
the  maniac  as  well  as  in  the  melancholiac.  To  be 
convinced  of  this,  it  suffices  but  to  recall  the  perfect 
serenity  with  which  the  maniac  receives  liews  of  a 
misfortune  in  his  famih'^  which,  in  the  normal  state, 
would  profoundly  distress  him. 

Psychic  inhil)ition  expressed  by  the  above  four 
sjnnptoms  is,  therefore,  the  fundamental  and  con- 
stant disorder  wliich  is  the  common  l3asis  of  the 
diverse  clinical  types  of  attacks  of  manic  depressive 
insanity. 

^  Psi/chitilrie,  7th  odition,  Vol.  II,  p.  504.  On  the  subject  of 
measurement  of  the  rapidity  of  the  associations  in  the  insane,  partic- 
ularly in  circular  insanity,  see  also  Ziehen's  contribution  in  Neurol. 
Centralbl.,  1896. 


MANIC  DEPRESSIVE  PSYCHOSES.  319 

The  symptoms  of  the  second  group  are  dependent, 
not  upon  psychic  inhibition,  but  upon  exaltation  of 
the  mental  automatism,  which  so  often  accompanies 
it.  The  principal  s^niiptoms  of  this  group  are: 
(a)  Flight  of  ideas;  (6)  irritability;  (c)  impulsive  re- 
actions; (d)  delusions  and  psycho-sensory  disorders; 
(e)  fixed  ideas  and,  occasionally,  imperative  ideas. 

All  these  morbid  phenomena  are  incidental. 
Their  presence  or  absence  modifies  the  aspect  but 
not  the  nature  of  the  attack.  Some  appear  with 
equal  frequency  in  mania  and  in  melancholia; 
namely,  delusions  and  hallucinations.  Others  are,  on 
the  contrary,  peculiar  either  to  the  one  or  to  the 
other  of  these  states:  flight  of  ideas,  irritability,  im- 
pulsiveness to  mania,  fixed  ideas  to  melancholia. 
But  there  is  no  absolute  rule  in  this  respect ;  we  meet 
with  depressed  cases  with  flight  of  ideas,  and  with 
cases  of  mania  in  which  the  delusions  are  more  or 
less  fixed. 

(2)  Alternation  of  excitement  and  depression  in  the 
same  subject.  —  The  close  relationship  existing  be- 
tween states  of  depression  and  maniacal  states  be- 
comes still  more  evident  when,  instead  of  considering 
a  single  attack,  we  make  a  study  of  all  the  attacks 
of  one  individual.  First  of  all,  it  is  extremely  rare 
for  a  patient  to  have  only  one  attack  of  mania 
or  of  melancholic  depression  in  his  life.  Thus 
isolated  and  non-recurring  mania  or  melancholic  de- 
pression is  almost  eliminated.  In  some  cases,  it  is 
true,  the  attacks  are  always  manic,  while  in  some 
others  they  are  always  depressed.  These  two 
groups,  apparently  separated  by  an  unfathomable 


320  MANUAL  OF  PSYCHIATRY. 

abyss,  are  in  reality  connected  by  a  much  larger 
group  of  double,  alternating,  circular,  and  irregular 
forms,  which  establish  an  insensible  transition  from 
the  one  to  the  other.  Moreover,  a  close  study  of 
cases  shows  that  the  majority  of  attacks  presenting 
the  manic  type  or  the  depressed  type  are  in  reahty 
attacks  of  double  form.  In  fact,  on  careful  inquiry 
we  fuid  that  almost  constantly  maniacal  symptoms 
are  preceded  by  a  prodromal  period  characterized 
by  more  or  less  marked  depression ;  again,  we  often 
find  an  attack  of  depression  to  be  followed  by  a  state 
of  excitement  which  cannot  be  attributed  to  any 
known  cause,  not  even  to  the  patient's  prospect  of 
returning  to  his  usual  mode  of  life  in  the  near  future. 
Thus  all  attacks  of  mania  and  of  melanchohc  de- 
pression contain  in  a  rudimentary  form  the  elements 
of  excitement  and  of  depression.  Circular  insanity 
thus  becomes  the  prototype  from  which  the  other 
types  are  derived. 

The  above  considerations  show  us  that,  in  spite 
of  the  apparent  diversity  of  the  symptoms,  mania, 
melancholic  depression,  and  their  various  combi- 
nations are  not  to  be  considered,  as  heretofore,  as 
different  morbid  entities,  and  that  the  following 
conclusion  arrived  at  by  Kraepelin  is  perfectly 
justifiable: 

' '  The  diverse  forms  which  have  been  described  are 
but  different  manifestations  of  one  and  the  same  funda- 
mental pathological  process,  equivalents,  like  the  many 
forms  assumed  by  epileptic  paroxysms."  ^ 


^  Kraepelin.     Psychialrie,  7th  edition,  V^ol.  II,  p.  558. 


MANIC  DEPRESSIVE  PSYCHOSES.  321 

Treatment.  —  For  the  treatment  of  the  symptoms 
wliich  may  arise  in  the  different  phases  of  manic  de- 
pressive insanity  the  reader  is  referred  to  the  general 
discussion  of  the  treatment  of  insanity  in  the  first 
part  of  this  book.  As  to  the  question  of  prevention 
of  recurrency  an  important  point  to  bear  in  mind  is 
the  necessity  of  insisting  upon  absolute  abstinence 
from  all  forms  of  alcoholic  beverages.  A  single  drink 
of  whiskey  has  been  known  to  act  as  the  undoubted 
cause  of  an  attack  in  a  manic  depressive  individual, 
and  there  are  some  cases  in  which  most  of  the  at- 
tacks are  attributable  to  overindulgence  in  alcohol. 

An  attempt  has  been  made  by  Kohn  to  prevent  the 
recurrency  of  attacks  in  cases  in  which  the  outbreaks 
are  brief  and  frequent  and  occur  with  such  regularity 
that  the  date  of  their  onset  can  be  predicted  with 
more  or  less  accuracy.  In  such  cases,  beginning 
several  days  before  the  expected  attack,  the  patient 
is  given  from  12  to  15  grams  of  sodium  bromide 
daUy  until  the  '^danger  period"  is  over,  when  the 
dose  is  gradually  diminished  and  the  drug  finally 
discontinued.  It  seems  in  some  cases  possible  to 
prevent  the  outbreaks  of  excitement  by  this  method 
of  treatment. 

§  5.   Chronic  Mania. 

The  diagnosis  of  chronic  mania  was  but  a  few 
years  ago  one  of  the  most  common  in  psychiatry. 
To-day  there  can  be  no  doubt  that  many  cases 
formerly  thus  labeled  belong  to  excited  forms  of 
dementia  prsecox,  particularly  catatonic  excitements: 
many,  but  not  all.     Chronic  mania,   though  rare, 


322  MANUAL  OF  PSYCHIATRY. 

certainly  infinitely  more  rare  than  was  believed  by 
older  authors,  constitutes  none  the  less  a  reality. 
Cases  exist  presenting  all  the  symptoms  character- 
istic of  the  manic  state  —  flight  of  ideas,  excitement 
morbid  imtability,  pressure  of  activity,  etc.  —  and 
in  which  these  symptoms,  instead  of  being  inter- 
mittent, become  established  in  definitely  chronic 
fashion. 

Clu-onic  forms  are  seen  chiefly  in  elderly  subjects, 
for  the  most  part  after  the  age  of  sixty  years.  They 
are  often  associated  with  a  certain  degree  of  in- 
tellectual enfeeblement  of  which  it  is  impossible  to 
say  whether  it  is  directly  dependent  upon  the  manic 
state  or  whether  it  constitutes  a  deterioration  of 
senile  origin  superimposed  somehow  upon  the  manic 
state.  When  we  consider  that  in  classical  manic 
depressive  insanity  even  severe  and  repeated  attacks 
leave  no  marked  intellectual  enfeeblement  the 
second  assumption  appears  more  logical. 

It  is  exceptional  for  a  chronic  manic  state  to  be  in- 
stalled as  such  from  the  beginning.  More  often  it 
follows  one  or  several  attacks  of  ordinary  manic  de- 
pressive insanity  ending  in  recovery.  The  patient 
has  one,  two,  three  attacks  from  which  he  recovers 
completely;  then  comes  on  another  attack  in  every 
way  resembling  the  previous  ones;  the  excitement 
subsides  somewhat,  periods  of  relative  calm  occur 
at  intervals;  recover^'  seems  to  be  approaching,  but 
the  condition  continues  indefinitely  and  it  finally  be- 
comes apparent  that  the  acute  maniac  has  become  a 
chronic  maniac.  At  times  the  chronic  state  is 
marked   by  extreme  weakness    of    attention;    this 


MANIC  DEPRESSIVE  PSYCHOSES.  323 

was  observed  in  the  following  case,  the  history  of 
which  I  shall  review  briefly,  and  which  may  serve 
as  a  general  type  from  several  points  of  view. 

Mrs.  C.  J.,  two  of  whose  cousins  are  insane,  was  bom  in  1844. 
In  1869,  that  is  to  say,  at  the  age  of  twenty-five  years,  following  a 
confinement,  she  had  an  attack  consisting  of  a  period  of  depression 
and  one  of  excitement,  the  whole  attack  lasting  eighteen  months. 
She  recovered  and  remained  well  until  1891,  when,  without  apparent 
cause,  she  had  another  similar  attack  from  which  she  recovered  at 
the  end  of  two  years,  following  a  surgical  operation  upon  the  uterus. 
In  1901  a  third  attack:  period  of  depression  lasting  several  months, 
later,  following  a  trip  on  wliich  she  was  taken  for  diversion,  sudden 
appearance  of  the  manic  state.  Another  surgical  operation  upon 
the  uterus  was  tried,  but  without  any  result.  Since  1901  excitement, 
flight  of  ideas,  and  logorrhoea  have  persisted  with  intervals  of 
lucidity  which  gradually  become  rarer  and  shorter.  These  intervals, 
which  at  first  lasted  several  days,  have  not  lasted  longer  than  one 
or  two  hours  during  the  first  half  of  1908.  At  the  present  time 
(September,  1908)  they  hardly  exceed  half  an  hour  and,  as  I  have 
already  mentioned,  they  are  notably  more  rare  than  during  the  first 
year  of  the  disease.  Moreover,  even  in  the  moments  of  lucidity 
which  still  occur  from  time  to  time  a  certain  degree  of  intellectual 
enfeeblement  is  observed.  Affectivity  is  reduced,  recollections  are 
lacking  in  precision,  attention  is  fixed  with  some  difficulty,  and 
orientation  of  time  is  defective.  There  seems  to  be  no  doubt  that 
we  are  here  dealing  with  a  state  of  chronic  mania  with  slight  in- 
tellectual enfeeblement.  The  most  pronounced  disorder,  the  one 
which  especially  characterizes  the  case  in  question  and  distmguishes 
it  from  attacks  of  manic  depressive  insanity  such  as  one  is  accus- 
tomed to  seeing,  is  an  extreme  weakness  of  attention,  a  weakness 
which  is  out  of  all  proportion  to  the  motor  excitement  and  which 
makes  it  impossible  to  obtain  a  sensible  reply  even  to  the  simplest 
questions,  while  at  the  same  time  it  is  easy  to  obtain  relative  psy- 
chomotor calm,  sufficient,  for  instance,  to  keep  the  patient  seated 
in  a  chair. 


CHAPTER  VI. 
INVOLUTIONAL  MELANCHOLIA. 

The  causes  of  this  disease  are  not  well  known. 
Neuropathic  heredity  has  been  found  in  about  60% 
of  the  cases.  The  most  frequently  mentioned  factors 
are  grief  and  stress.  Occurring  chiefly  after  forty- 
five  years  of  age,  it  seems  to  be  intimately  con- 
nected with  the  phenomena  of  organic  retrogression 
beginning  at  this  age;  hence  the  name  "involutional 
melancholia.'^  "■ 

The  prodromal  period,  which  is  almost  constant 
and  usually  very  long,  indicates  a  profound,  slow, 
and  progressive  change  of  the  entire  organism:  the 
process  of  digestion  is  painful;  there  are  anorexia, 
insomnia,  irritability,  unwarranted  pessimism,  and  a 
tendency  to  rapid  fatigue. 

Finally  the  disease  sets  in,  characterized  from  the 
beginning  by  intense  psychic  pain. 
•  It  presents  itself  with  the  train  of  physical  and 
psychic  sjTuptoms  already  studied  in  connection 
with  active  depression.  When  associated  with  anx- 
iety it  gives  rise  to  anxious  melancholia.^ 

The  anxiety  may  result  either  in  agitation  {melan- 
cholia agitata)  or  in  stupor.     In  the  latter  case  the 

^  Capgras.  Essai  de  reduction  del  a  melancolie  a  une  psychose 
d'involutkm  presenile.  These  de  Paris,  1900.  —  Kraepelin.  Lehr- 
biich  der  Psijchiatrie. 

324 


INVOLUTIONAL  MELANCHOLIA.  325 

patient  appears  as  though  dumbfounded  by  the 
pam.  "A  frightful  internal  anxiety  constitutes  the 
fundamental  state,  which  torments  him  almost  to 
suffocation."^ 

WTien  the  psychic  pain  is  very  marked,  it  entails 
sometimes  a  certain  degree  of  mental  confusion  which 
is  most  frequently  transitory  and  su5ject  to  the 
same  fluctuations  as  the  pain  itself  of  which  it  is  a 
manifestation. 

In  cases  of  slight  or  moderate  intensity  the  lucidity 
is  perfect  and  sometimes  permits  the  patient  to 
analyze  his  case  with  considerable  minuteness. 

Association  of  ideas  is  sluggish,  less  so,  however, 
than  in  the  depressed  form  of  manic  depressive  in- 
sanity. We  have  seen,  in  fact,  that  the  intensity  of 
psychic  inhibition  is  inversely  proportional  to  that 
of  psychic  pain;  naturally,  therefore,  the  inhibition 
occupies  here  a  secondary  position.  Between  the 
cases  in  which  the  sadness  clearly  predominates  and 
those  in  which  the  inhibition  is  the  principal  feature, 
there  is  a  host  of  intermediary  forms  which  estab- 
lish an  insensible  transition  between  involutional 
melancholia  and  manic  depressive  insanity.  These 
two  affections  seem  to  be  closely  related  to  each 
other,  and  borderland  cases  are  not  uncommon. 

The  recent  study  of  Dreyfus-  indicates  clearly 
that  the  relationship  between  involutional  melan- 
cholia and  manic  depressive  insanity,  here  pointed 
out,  is,  indeed,  a  very  close  one.     This  study  con- 

1  Griesinger.     Loc.  cit.,  p.  292. 

2  Die  Melancholie  ein  Zustandsbild  des  manisch-depressiven 
Irreseins.     Jena,  1907, 


326  MANUAL  OF  PSYCHIATRY. 

sists  in  a  careful  investigation  of  the  entire  subse- 
quent course  of  all  cases  admitted  to  the  Heidelberg 
clinic  since  1892  and  classified  as  involutional  melan- 
cholia. The  facts  revealed  by  the  investigation 
are:  the  great  majority,  of  the  cases  which  had  not 
tenninated  in  death  through  some  complication  re- 
sulted in  complete  recovery;  in  a  small  percentage 
of  the  cases  deterioration  ultimately  occurred  ap- 
jiarently  on  a  basis  of  cerebral  arteriosclerosis  which 
such  cases  seem  to  be  particularly  prone  to  develop; 
more  than  half  of  the  cases  had  more  than  one  at- 
tack; in  many  cases  manic  symptoms  were  observed: 
fleeting  euphoria,  irritability,  loquaciousness,  flight 
of  ideas,  etc.  These  results  led  Dreyfus  to  the  con- 
clusion that  involutional  melancholia  was  but  a 
special  variety  of  mixed  form  of  manic  depressive 
insanity;  and  Kraepelin  in  a  preface  contributed  by 
hmi  to  the  work  of  Drej^us  evidently  accepts  this 
conclusion  in  the  following  words:  ''These  results 
show,  at  least  for  the  main  bulk  of  the  cases  which 
we  have  designated  as  involutional  melancholia, 
that  there  is  no  longer  any  basis  compelling  their 
sei)aration  from  manic  depressive  insanity." 

Thus  it  would  seem  that  the  autonomy  of  involu- 
tional melancholia  as  an  independent  clinical  entity 
is  destroyed.  We  have,  however,  allowed  the  de- 
scription of  it  in  this  "Manual  to  remain,  partly 
for  the  reason  that  it  still  figures  in  hospital  statistics, 
but  mainly  for  the  reason  that,  admitting  its  kinship 
to  manic  depressive  insanity,  it  nevertheless  presents 
special  and  characteristic  features,  among  which  may 
be  mentioned   its   frequent   development   following 


INVOLUTIONAL  MELANCHOLIA.  327 

actual  depressing  causes  (death  of  a  near  relative, 
financial  ruin) ;  its  grave  form  characterized  by  long 
duration  (in  many  cases  over  five  years,  in  some 
over  ten  years),  frequent  fatal  termination,  combi- 
nations of  symptoms  not  commonly  observed  in 
typical  attacks  of  manic  depressive  insanity;  the 
occurrence  in  nearly  half  of  the  cases  of  only  one 
attack  during  the  life  of  the  individual. 

The  sadness  may  in  itself  become  a  cause  of 
psychic  inhibition  and  create  melancholia  with 
stupor. 

To  these  psychic  phenomena  are  added  physical 
disorders  most  of  which  have  already  been  con- 
sidered : 

Respiratory  and  circulatory  disturbances  which 
are  dependent  upon  the  depression  and  anxiety. 

Disturbance  of  the  digestive  functions:  anorexia, 
dyspepsia,  painful  digestion,  constipation. 

Impairment  of  the  general  nutrition,  changes  in 
the  composition  of  the  urine  (diminution  of  urea, 
slight  albuminuria),  and  rapid  loss  of  flesh.  The 
latter  symptom  is  of  particular  importance:  a  rise 
in  weight  usually  indicates  that  the  patient  is  enter- 
ing upon  his  convalescence. 

The  menses  are  usually  suppressed.  Their  reap- 
pearance has  the  same  prognostic  significance  as  the 
return  of  the  normal  weight:  it  indicates  the  ap- 
proach of  recovery. 

Finally,  there  are  various  nervous  troubles:  head- 
ache, palpitation,  tremors,  hysteriform  crises,  and 
insomnia. 

These  are  the  fundamental  symptoms  of  involu- 


328  MANUAL  OF  PSYCHIATRY. 

tional  melancholia  in  its  simplest  form  and  uncom- 
plicated by  delusions.  This  form  is  rare;  generally 
the  disease  assumes  one  of  the  following  two  forms, 
or  some  combination  of  the  two:  anxious  melan- 
cholia and  delusional  melancholia. 

Anxious  melancholia.  —  The  psychic  pain,  which  is 
here  very  intense,  manifests  itself  by  the  mental  and 
physical  symptoms  of  anxiety,  which  have  already 
been  described  in  the  first  part  of  this  book :  more  or 
less  complete  cessation  of  mental  processes,  in  some 
cases  a  certain  degree  of  mental  confusion  at  the 
time  of  the  paroxysms  of  anxiety;  an  extremely  dis- 
tressing sense  of  constriction  generally  localized  in 
the  precordial  region  or  in  the  throat,  less  often  in 
the  head;  pallor  and  pinched  expression  of  the  face, 
coldness  and  cyanosis  of  the  extremities,  irregular 
and  shallow  respirations;  lowering  of  blood  pressure; 
small,  compressible  pulse,  either  rapid  or  slow;  dila- 
tation of  the  pupils. 

From  the  point  of  view  of  the  reactions  anxious 
melancholia  is  characterized  either  by  agitation  or 
by  stupor. 

The  agitation  of  melancholia  presents  the  appear- 
ance of  despair :  the  patient  wrings  his  hands,  strikes 
his  head  against  the  walls,  and  gives  vent  to  lamen- 
tations and  heart-rending  cries.  It  is  monotonous 
and  often  marked  by  very  pronounced  negativism. 
The  phenomena  of  agitation  are  sometimes  purely 
impulsive  in  origin  and  occur  in  the  shape  of  sudden 
attacks  which  may  be  very  brief.  During  such  at- 
tacks the  patients  may  display  a  tendency  to  violent 
acts  of  danger  to  themselves  or  to  others  (suicidal  or 


INVOLUTIONAL  MELANCHOLIA.  329 

homicidal  attempts).  Such  paroxysms  constitute 
the  so-called  raptus  melancholictLS. 

Psychic  pain  may,  like  physical  pain,  paralyze 
more  or  less  completely  all  mental  functions.  Thus 
is  explained  the  manner  in  which  anxious  melan- 
cholia may  become  transformed  into  stuporous  mel- 
ancholia; these  two  forms,  seemingly  so  different, 
are  in  reality  closely  related.  The  psychic  inhibition 
which  characterizes  stuporous  melancholia  is  essen- 
tially a  secondary  phenomenon. 

Anxious  melancholia  sometimes  exists  in  a  state 
of  purity,  either  as  agitated  melancholia  or  as 
stuporous  melancholia.  Much  more  often  it  is  com- 
plicated by  delusions. 

Delusional  melancholia.  —  All  varieties  of  melan- 
choly delusions  are  encountered  in  this  affection: 
ideas  of  culpability,  of  humility,  of  ruin,  hypo- 
chondriacal ideas,  and  ideas  of  negation.  The 
syndrome  of  Cotard  scarcely  ever  appears.  It  is 
not  uncommon  for  persecutory  ideas  to  occur  in 
combination  with  melancholy  ideas  proper. 

Hallucinations  are  not  frequent.  The  least  rare 
are,  according  to  Seglas,  those  of  vision  and  of  the 
muscular  sense.  Those  of  hearing,  taste,  and  smell 
are  occasionally  met  with,  while  those  of  general 
sensibility  are  altogether  exceptional. 

Illusions  of  all  sorts  are,  on  the  contrary,  fre- 
quent. They  often  assume  the  form  of  mistakes  oj 
identity. 

Finally,  delusional  interpretations  are  constant. 
The  patient  hears  the  noise  of  hammer-strokes  in  the 
vicinity  and  thinks  a  scaffold  is  being  built  for  him. 


330  MANUAL  OF  PSYCHIATRY. 

He  hears  the  sound  of  voices  in  the  street  and  thinks 
the  mob  is  going  to  seize  and  lynch  him,  etc. 

The  reactions  are  usually  in  harmony  with  the 
melancholy  state  and  with  the  nature  of  the  de- 
lusions. Sometimes,  under  the  influence  of  anxiety 
which  in  many  cases  accompanies  the  delusions,  the 
reactions  assume  an  exclusively  automatic  character; 
it  is  to  be  noted  that  negativism  is  not  uncommon. 

The  following  case  illustrates  both  delusional 
melancholia  and  anxious  melancholia. 

Margaret  L.,  fifty-eight  years  old.  —  Paternal  and  maternal 
heredity:  father  was  alcoholic,  died  of  disease  of  the  liver;  mother 
eccentric,  unduly  irritable;  one  maternal  aunt  committed  suicide.  — 
The  patient  lias  always  been  nervous  and  sensitive.  She  has  been, 
however,  of  normal  intelligence  and  always  attended  properly  to 
the  work  of  her  home  and  family.  She  has  two  daughters,  respec- 
tively thirty  and  twenty-five  years  old,  both  normal.  Menstruation 
ceased  two  years  ago. 

The  mental  symptoms  began  with  a  state  of  general  depression 
and  discouragement.  On  being  invited  to  a  christening  of  a  little 
boy  she  refused  to  go,  giving  as  her  reason  that  life  is  a  burden  and 
that  there  is  no  cause  for  rejoicing  in  the  birth  of  a  child.  After 
several  weeks  she  began  to  show  very  marked  uneasiness  and  a 
little  later  <lelusional  interpretations.  She  saw  wagons  jiassing 
by  the  hf)us(>  loadcnl  with  various  objects,  furniture,  bedding, 
barrels,  sacks  of  flour;  she  heard  the  drivers  cracking  their  wliips; 
all  this  alarmed  her  greatly  and  she  asked  her  husband  whether 
all  this  did  not  signify  that  she  was  to  be  thrown  out  of  the  house 
and  left  to  starve  to  death.  She  noticed  also  that  the  neighbors 
looked  at  her  (jueerly  whenever  she  met  them.  At  the  .same  time 
ph\'sical  symptoms  ajji^eared:  coini)lete  loss  of  appetite,  hea<laches, 
insomnia.  About  two  weeks  later,  nam(>ly,  March  20,  HKX),  she 
developed  an  idea  of  sc^lf-acciisation.  About  twenty-fiv(>  years  ago 
she  lost  a  little  daughter  from  croup.  Did  not  this  child  die 
because  its  mother  had  left  it  one  day  with  its  feet  wet?  This 
idea  at  first  had  the  character  of  an  imperative  idea;  the  patient 
knew  it  was  false  and  tried  to  drive  it  away;  it,  however,  grew 
more  and  more  dominating  and  was  finally  accepted  by  the  patient 


INVOLUTIONAL  MELANCHOLIA.  331 

as  true:  the  imperative  idea  became  a  fixed  idea.  The  psychic 
pain  increased  steadily.  New  delusions  sprang  up,  the  first  one, 
however,  still  remaining  active.  On  April  12  the  patient  went  to 
the  police  headquarters  carrying  a  bundle  of  clothing;  this,  she 
said,  was  for  those  poor  girls  who  are  robbed  of  everything  and 
thrown  out  into  the  street.  At  the  same  time  she  begged  the 
poUce  authorities  to  send  men  to  protect  those  unfortunate  women 
whom  the  Prussians  were  about  to  ravish. 

On  being  taken  to  a  sanitarium  she  did  not  cease  to  wail  and  to 
lament,  first  accusing  herseK,  as  formerly,  of  the  death  of  her  little 
girl,  later  of  the  illness  of  her  husband,  who  really  did  have  heart 
trouble.  Gradually  the  delusions  grew.  She  claimed  she  had 
brought  upon  her  relatives  such  disgrace  and  misery  that  they  all 
committed  suicide;  the  letters  which  she  is  supposed  to  receive 
from  them  are  false;  no  doubt  this  is  done  to  console  her;  every- 
body has  been  too  good  to  her;  a  nasty  creature  like  her  should 
have  her  head  chopped  off.  There  she  is,  well  fed  and  housed, 
and  warmly  dressed,  yet  they  know  well  that  she  has  no  money  to 
pay  for  all  tliis.  But  tliis  cannot  last;  pretty  soon  the  day  will 
come  when  they  will  put  her  out  to  go  and  beg.  She  developed  a 
few  hallucinations  of  sight,  of  hearing,  and  of  muscular  sensibiUty: 
several  times  she  saw  before  her  a  pool  of  blood;  also  several  times 
she  heard  the  voices  of  her  children  crying:  "Bread!  Give  us 
bread!"  Finally  she  complained  of  feeling  an  inner  voice  coming 
from  her  breast,  which  made  her  say  against  her  own  will:  "Slut! 
slut!"  She  cries  loudly,  begging  to  be  put  to  death;  has  made 
repeated  attempts  to  commit  suicide;  from  April  21  to  October  30, 
five  such  attempts  were  counted,  three  of  which  were  by  hanging. 
For  a  time  she  refused  food;  after  being  tube-fed  for  two  days, 
she  began  to  eat  again,  although  with  much  difficulty. 

Considerable  emaciation.  Tongue  coated.  Breath  very  foul. 
Constipation.     Slight  trace  of  albumen  in  the  urine. 

Such  is  the  fundamental  and  habitual  state  of  the  patient.  The 
anxiety,  without  being  ever  entirely  wanting,  presents,  however, 
periods  of  exacerbation,  so  that  the  patient  at  times  shows  the 
tyiiical  picture  of  anxious  melancholia.  During  such  paroxysms 
the  patient  seems  to  be  literally  suffocating.  She  seems  to  be 
striving  to  throw  off  a  weight  from  her  chest;  she  pulls  her  hair, 
strikes  herself  in  the  face,  and  -scratches  at  the  walls  of  her  room 
until  her  fingers  bleed.  When  her  agitation  is  at  its  height  it  is 
impossible  to  obtain  from  her  a  response  to  any  question.     She 


332  MANUAL  OF  PSYCHIATRY. 

merely  utters  inarticulate  erics  or  repeats  in  a  low,  scarcely  audible 
voice:  "My  God!  .  .  .  My  God!  .  .  ."  Her  consciousness  is  then 
evidently  profoundly  affected  and  it  seems  that  even  delusions  at 
such  times  disappear  under  the  influence  of  the  psychic  pain  and 
the  anxiety. 

Towards  the  latter  part  of  November,  1900,  the  general  condi- 
tion of  the  patient  improved.  Her  appetite  became  better.  The 
delusions  persisted  and  the  patient  continuetl  her  lamentation, 
but  the  reactions  became  less  pronounced.  Little  by  little  the 
delusions  also  became  less  active.  A  certain  de|?ree  of  mental 
activity  returned.  Towards  the  middle  of  December  the  patient 
was  able  to  do  some  manual  work.  She  returned  home,  com- 
pletely cured,  February  6,  190L  At  the  present  time  (1905)  she 
is  still  perfectly  well. 

Prognosis.  —  Melancholia  may  terminate  in: 

(a)  Complete  recovery,  66%;       jy^ 

(b)  Dementia  due  to  the  development  of  cerebral 
arteriosclerosis,  8%;  /.. 

(c)  Death,  25%/  which  may  be  due  to: 

(I)  Suicide,  which  is  the  more  likely  to  occur  the 
more  pronounced  the  psychic  pain  and  the  less 
marked  the  inhibition.  The  melancholiac  may  com- 
mit suicide  at  any  period  of  his  illness,  even  during 
convalescence,  when  on  account  of  a  real  or  fictitious 
gaiety,  supervision  over  him  is. relaxed; 

(II)  To  melancholic  wasting,  the  principal  factors  of 
which  are  intense  sadness,  anxiety,  agitation,  and 
insufficient  alimentation  occasioned  by  a  poor  con- 
dition of  the  digestive  tract,  by  a  delusion,  or  by  a 
suicidal  idea; 

(III)  To  some  complication  the  occurrence  of  which 
is  favored  by  the  defective  nutrition  of  the  tissues: 
pneumonia,  influenza,  tuberculosis. 

1  Dreyfus.     Loc.  cit.,  p.  269. 


INVOLUTIONAL  MELANCHOLIA.  333 

The  duration  of  the  affection  is  very  variable,  from 
several  weeks  to  a  few  years. 

Treatment.  —  The  principal  indications  are: 

To  watch  the  patient  with  a  view  to  the  prevention 
of  suicide; 

To  support  his  strength; 

To  calm  agitation  if  there  is  any; 

To  pay  special  attention  to  the  alimentation. 

The  first  three  indications  are  admirably  fulfilled 
by  rest  in  bed. 

Forced  alimentation  is  often  necessary  to  fulfill 
the  fourth. 

The  psychic  pain  may  be  efficaciously  combated  by 
the  administration  of  opium  in  increasing  doses. 
One  may  start  with  15  minims  of  the  tincture  per 
day,  increase  to  60  minims  or  more,  and  then  grad- 
ually reduce  the  quantity  to  the  initial  dose  before 
discontinuing  the  treatment. 

Finally,  continuous  warm  baths  may  be  of  service 
in  the  agitated  forms. 


CHAPTER  VII. 

HYSTERIA.  —  CONSTITUTIONAL  PSYCHOPATHS.  — 
MORAL  INSANITY. 

§  1.  Hysteria. 

To  make  a  complete  study  of  the  mental  disorders 
of  hysteria  would  mean  to  consider  the  entire  cUnical 
history  of  this  neurosis,  for  hysteria  is  essentially  a 
mental  affection.  It  is,  however,  the  custom  to  leave 
a  considerable  portion  of  this  subject  to  neurologj% 
reserving  for  psychiatry  the  phenomena  belonging  to 
its  own  sphere,  not  only  by  origin,  but  also  by  their 
aspect.  The  paralyses,  contractures,  anaesthesias, 
in  a  word  all  the  somatic  symptoms,  will  therefore 
be  systematically  omitted  from  the  following  de- 
scription. 

The  mental  disorders  of  hysteria  are  all  dependent 
upon  the  predominance  of  the  automatism  over  the 
voluntary  and  conscious  psychic  operations.  These 
disorders  are  classified  as  permanent  and  paroxysmal. 

Permanent  mental  disorders.  —  These  constitute 
the  mental  stigmata  of  Janet, ^  and  impart  to  the  per- 
sonality of  the  hysterical  subject  its  peculiar  clinical 
aspect.     The  following  are  the  principal  ones: 

(a)  Weakening  and  mobility  of  attention ,  which  no 
longer  directs  the  associations  of  ideas,  thus  leaving 
uncontrolled  the  mental  automatism.  In  some  cases 
the  patient  lives  as  in  a  dream  in  which  images  and 

^  Pierre  Janet.     Etat  incntal  des  hyateriques. 
334 


HYSTERIA.  335 

ideas  follow  each  other  without  order  or  logical 
sequence.  In  other  cases  the  automatism  assumes 
the  form  of  a  fixed  idea  upon  which  the  affective 
phenomena  and  the  reactions  are  dependent.  Al- 
most always  subconscious,  the  hysterical  fixed  idea 
requires  a  careful  search  for  its  discovery  and  often 
cannot  be  revealed  except  during  hypnotic  sleep. 

(6)  Disorders  of  memory;  amnesia  of  reproduction: 
recollections  cannot  be  evoked  at  will  though  they 
may  still  arise  automatically;  this  amnesia  of  re- 
production is  often  partial  and  in  its  course  is  subject 
to  numerous  remissions  and  exacerbations;  its  dura- 
tion is  very  variable,  from  a  few  minutes  to  several 
years;  illusions  and  hallucinations  of  memory  form 
the  basis  of  pseudo-reminiscences  remarkable  for  their 
vividness,  their  wealth  of  detail,  and  their  quite 
plausible  character:  they  result  from  extreme  sug- 
gestibility and  often  originate  from  a  story  the 
patient  has  read  or  from  an  event  narrated  in  his 
presence. 

(c)  Changes  of  affectivity  and  of  disposition:  morbid 
indifference  associated  with  great  variability  of 
moods,  egoism,  sensitiveness,  and  a  morbid  desire 
to  attract  attention.  The  hysterical  subject  thus 
resembles  closely  the  constitutional  psychopath. 

The  morality  of  hysterical  subjects  has  been  much 
discussed  with  special  reference  to  their  duplicity  and 
tendency  to  prevarication.  Some  see  in  the  false- 
hoods of  the  patients  nothing  but  errors  attributable 
to  amnesia;  others,  less  tolerant,  consider  these  false- 
hoods as  intentional,  and  see  in  them  a  sign  of  per- 
versity. 


336  MANUAL  OF   PSYCHIATRY. 

Both  opinions  are  partly  true.  It  is  certain  that  these 
patients  often  connnit  errors  unconsciously,  but  it  is 
equally  certain  that  they  also  prevaricate  knowingly. 
The  common  phrase  hysterical  lies  is  not  an  unjustified 
one. 

id)  Anomalies  of  sexual  life  :  sometimes,  much  less 
frequently  than  is  commonly  claimed,  hysterical  sub- 
jects present  erotic  tendencies;  much  more  often  there 
is  frigidity  with  or  without  sexual  perversion. 

(e)  Weakening  of  the  will :  aboulia  is  a  constant 
phenomenon  and  manifests  itself  in  apathy  and  negH- 
gence.  Though  occasionally  the  patient  gives  evidence 
of  feverish  activity,  the  duration  of  this  activity  is  but 
brief  and  the  subsequent  reaction  is  marked  by  an 
exaggeration  of  the  aboulia. 

Automatic  reactions  replace  voluntary  ones  and 
are  met  with  in  the  most  varied  forms:  pathological 
suggestibility,  catalepsy,  i)assionate  impulses,  etc. 

Episodic  mental  disorders.  —  These  may  either  accom- 
pany the  hysterical  attacks  or  occur  independently  of 
them. 

(a)  Mental  disorders  associated  with  the  attacks.  — 
These  are: 

(1)  Before  the  crisis:  an  accentuation  of  the  ordinary 
anomalies  of  the  character;  sonK^tiincs  appears  a  hallu- 
cination, a  fixed  idea. 

(2)  During  tlie  crisis :  lialhicinations,  delusions,  or 
motor  excitement  may  partly  or  completely  replace  the 
ordinary  hysterical  phenomena  (maniacal  or  ecstatic 
form  of  crisis). 

(3)  After  the  crisis:  delusional  states  associated  with 
multiple  combined  hallucinations  which  are  often  of  an 


HYSTERIA.  337 

erotic  nature  and  which  may  give  rise  to  passionate 
attitudes  and  movements. 

(6)  Among  the  mental  disorders  occurring  independently 
of  the  attacks  an  important  one  is  somnambulism,  spon- 
taneous or  induced;  it  presents  the  most  perfect  form 
of  psychic  automatism. 

Closely  related  to  somnambulism  are  the  hysterical 
states  of  obscuration,  which  present  themselves  in  two 
different  forms:  (a)  the  stupid  form,  characterized 
by  mental  hebetude  and  absence  of  reactions;  (/?)  the 
agitated  form,  characterized  by  violent  reactions  and 
excitement  associated  with  confused  delirium.  Some- 
times the  excitement  is  so  pronounced  as  to  simulate 
epileptic  dehrium.  The  duration  of  the  attack  is 
scarcely  ever  more  than  a  few  days. 

Hysterical  subjects  may  also  have  acute  attacks 
resembling  manic  depressive  insanity,  which  are  known 
as  hysterical  mania  and  melancholia.  I  shall  return  to 
this  subject  in  connection  with  the  differential  diagnosis. 

A  positive  diagnosis  of  hysterical  mental  disorders 
is  chiefly  to  be  based  upon  the  existence  of  the  psychic 
stigmata  mentioned  at  the  beginning  of  this  chapter 
and  of  the  physical  stigmata  which  are  described  in 
all  works  on  neurology:  clavus  or  globus  hystericus, 
ovaralgia,  anaesthesia,  monoplegia,  visceral  disorders 
such  as  obstinate  vomiting,  palpitation,  etc. 

The  differential  diagnosis  from  the  following  conditions 
is  sometimes  very  difficult: 

(a)  Catatonia.  — The  problem  is  a  complicated  one, 
since  most  of  the  catatonic  phenomena  may  be  en- 
countered in  hysteria,  also  most  of  the  hysterical 
symptoms,  nervous  and  psychic,  may  occur  in  catatonia. 


338  MANUAL  OF   PSYCHIATRY. 

The  only  certain  differential  feature  is  intellectual 
enfeeblement,  which  is  almost  constant  in  catatonia  and 
altogether  exceptional  in  hysteria.  Before  its  appear- 
ance the  diagnosis  remains  doubtful,  and  can  only  be 
surmisetl  from  the  following  features:  psychic  disaggre- 
gation is  more  marked  in  catatonia,  resulting  in  true 
incoherence;  the  symptoms  in  catatonia  have  a  more 
stable  character;  stereotypy  is  more  marked;  emotional 
indifference  is  more  pronounced ;  there  is  no  subconscious 
fixed  idea. 

(6)  Epilepsy. —  Unconsciousness  during  the  seizure, 
subsequent  amnesia,  which  is  more  constant  and 
more  complete  in  ei)ilepsy  than  it  is  in  hysteria,  and 
the  nature  of  the  convulsive  seizures  servo  as  a  basis 
for  the  diagnosis,  which  is  in  some  instances  very  diffi- 
cult to  establish.  Moreover  it  seems  that  hysteria  and 
epilepsy  may  exist  together  in  the  same  subject. 

(c)  Mania.  —  Here  the  excitement  is  usually  more 
continuous  and  less  affected  by  external  influences, 
such  as  the  presence  of  spectators,  which  always  increases 
the  excitement  of  hysteria;  flight  of  ideas  is  much 
more  distinct;  hallucinations  are  more  rarely  seen. 

(d)  Melancholic  depression.  —  The  depression  is  con- 
tinuous and  durable  and  is  independent  of  external 
influences,  while  in  the  hysterical  patient  a  ])leasantry 
or  a  word  of  encouragement  often  suffices  to  dissipate, 
at  least  momentarily,  the  melancholic  phenomena. 
Manifestations  of  psychic  automatism  are  much  less 
marked  in  melancholic  depression  than  in  hysteria. 

The  prognosis  of  hysteria  is  grave.  The  episodic 
mental  disorders  usually  subside,  either  sjiontaneously 
or  under  the  influence  of  treatment;  but  the  hysterical 


CONSTITUTIONAL  PSYCHOPATHS.  339 

disposition  remains  and  renders  recurrency  of  attacks 
probable. 

The  treatment  ^  consists  in  rest,  isolation,  hydro- 
therapy, and  mental  suggestion,  which,  with  or  without 
hypnosis,  produces  marvelous  results;  also  attention 
to  the  somatic  disturbances  so  frequent  in  hysteria 
is  of  importance. 

Excitement  is  to  be  treated  by  the  usual  methods. 
Isolation  often  produces  very  happy  results. 


§  2.   Constitutional  Psychopaths. 

There  are  some  persons  who  present  from  child- 
hood evident  psychic  anomalies  which  justify  their 
being  classed  in  a  separate  group,  —  the  constitu- 
tional psychopaths. 

From  this  group  must  be  eliminated  epileptics, 
hysterical  subjects,  paranoiacs,  and  the  feeble- 
minded, which,  in  spite  of  their  close  relationship  to 
the  psychopaths,  really  form  independent  categories. 
Such  distinctions  are  necessary  for  the  avoidance  of 
confusion  in  the  theory  and  practice  of  psychiatry. 

We  shall  study  first  the  habitual  mental  state  of 
psychopaths,  then  the  anomalies  of  sexual  life,  which 
on  account  of  their  importance  merit  a  separate  de- 
scription, and  finally  obsessions. 

Habitual  mental  state  of  psychopaths.  —  The  prin- 
cipal anomalies  are  those  of  (a)  judgment,  (6)  the 
character,  and  (c)  conduct.  ""  ^ 

(a)  Disorders  of  judgment.  —  These  constitute  per- 
haps the  most  essential  stigma  of  the  psychopath  as 
well  as  the  most  important  one  from  the  social  stand- 

1  Sollier.    L'hysterie  et  son  traitement.     Paris,  F.  Alcan. 


340  MANUAL  OF  PSYCHIATRY. 

point.  The  psychopath  does  not  see  things  in  their 
proper  light,  hence  his  singular  notions,  his  paradoxes, 
his  ridiculous  enterprises. 

Usually  he  presents  a  more  or  less  pronounced 
state  of  feeble-mindedness,  weakness  of  attention  or 
of  memory,  sluggish  formation  of  associations  of 
ideas,  and  poverty  of  imagination.  In  some  cases, 
however,  some  of  the  faculties  are  normal  or  even 
brilliant:  memory,  imagination,  or  artistic  apti- 
tudes. But  these  abilities  cannot  be  turned  to 
account  by  reason  of  the  lack  of  judgment,  for  al- 
most always,  if  he  is  not  actually  feeble-minded,  the 
psychopath  is  at  least  mentally  unbalanced. 

(6)  Anomalies  of  the  character.  —  These  are  very 
varied.  Sometimes  they  consist  in  a  general  pessi- 
mism: the  patient  sees  only  the  dark  side  of  life; 
all  occurrences  make  a  painful  impression  upon  his 
mind. 

Usually  the  dominant  note  in  the  character  of  the 
psychopath  is  extreme  mobility  of  the  emotions.  The 
subject  passes  alternately  from  exuberant  joy  to 
boundless  desolation,  from  feverish  activity  to  pro- 
found discouragement,  from  affection  to  hatred, 
from  the  most  complete  egoism  to  the  most  exagger- 
ated generosity  and  devotion.  Thus  the  expression 
unbalanced  is  perfectly  applicable  to  this  class  of 
patients. 

(c)  The  conduct  shows  insufficiency  of  judgment 
and  instability  of  the  emotions.  It  is  full  of  con- 
tradictions. 

The  psychopath  is  apt  to  pose  as  a  champion  of 
justice,  as  an  avenger  of  humanity.     He  is  given  to 


CONSTITUTIONAL  PSYCHOPATHS.  341 

anarchistic  ideas,  seeks  to  interfere  in  public  affairs, 
to  become  a  leader  of  popular  movements  —  and 
succeeds  but  too  often.  His  conduct  is  often  incon- 
sistent with  his  ideas  of  justice  and  charity,  though 
he  fails  to  see  it  himself.  Theoretically'  he  strives  for 
the  good  of  the  universe,  practically  for  the  satis- 
faction of  his  own  egoistic  tendencies. 

He  tries  all  sorts  of  occupations,  but  succeeds  in 
none,  and  accuses  his  fate  or  the  injustice  of  men. 
He  is  apt  to  pose  as  a  victim,  while  in  reaUty  he  is 
what  is  aptly  designated  by  the  popular  expression 
"a  ne'er-do-well."  If  he  has  no  personal  resources 
and  if  he  is  not  aided  by  his  relatives  or  by  pubhc 
charity  he  becomes  a  vagabond. 

The  psychic  anomalies  are  often  associated  with 
physical  ones,  which  are  spoken  of  as  physical  stig- 
mata of  degeneration.  Most  of  these  abnormalities 
may  be  encountered  in  normal  individuals.  Only 
the  combination  of  many  of  them  in  the  same  sub- 
ject renders  them  of  importance;  they  are  more 
numerous  in  the  insane,  constitutional  psychopaths, 
epileptics,  and  hysterical  individuals  than  they  are 
in  normal  persons.  They  possess  some  theoretical 
interest,  but  are  not  of  great  practical  interest; 
therefore  I  shall  limit  myself  to  the  mere  mention  of 
the  principal  ones. 

Cranial  malformations:  macrocephaly,  micro- 
cephaly, scaphocephaly,  extreme  brachycephaly,  or 
dolichocephaly;  cranio-facial  asymmetrj^,  harelip, 
malformations  of  the  palate;  dental  anomalies: 
congenital  absence  of  one  or  several  teeth,  inegu- 
larities  of  implantation,  malformations;    anomalies 


342  MANUAL  OF  PSYCHIATRY. 

of  the  auricle:  defective  lobule,  abnormal  develop- 
ment of  the  Darwinian  tubercle,  absence  of  the  helix; 
irregular  pigmentation  of  the  irides,  strabismus; 
malformations  of  the  external  genital  organs:  cryp- 
torchydism,  infantilism,  hypo-  or  epispadias,  pseudo- 
hemaphroditism;  anomalies  of  the  length  of  the 
limbs:  oligodactylism,  etc. 

Together  with  the  anatomical  anomalies  should  be 
ranged  the  numerous  tattooings  with  which  many 
psychopaths  are  covered,  and  which  may  indicate  a 
morbid  mental  state. 

Tattoo-marks,  so  frequently  observed  among  the 
insane  and  among  criminals,  are  a  sort  of  acquired 
sign  of  degeneration.^ 

Anomalies  of  sexual  life.^  —  We  usually  distin- 
guish: 

(A)  Anomalies  of  degree:  eroticism;  frigidity. 

(B)  Anomalies  of  nature:  sexual  perversion; 
sexual  inversion. 

(A)  Anomalies  of  degree.  —  Eroticism  results  in 
venereal  excesses  and  often  in  indecent  acts  and  at- 
tempts of  rape. 

Sexual  frigidity  consists  in  an  indifference  and  even 
an  aversion  of  the  subject  to  sexual  connection;  at 
least  to  normal  sexual  connection,  for  frigidity  may 
be  associated  with  sexual  perversion  or  inversion. 
A  curious  and  apparently  paradoxical  fact  is  its  fre- 
quency among  prostitutes. 

(B)  Anovialies  of  nature.  —  (a)  Sexual  perversion 
consists  in  the  abnormal  character  of  the  conditions 

1  Martin.     Les  tatouages  chcz  Ics  alienes.     These  de  Paris,  1900. 

2  KxafTt-Ebing.     Psychoixithia  Sexualis. 


CONSTITUTIONAL  PSYCHOPATHS.  343 

necessary  to  excite  sexual  desire  and  sometimes  its 
gratification.  Its  most  common  forms  are  masturbor- 
tion,  fetichism,  exhibitionism,  sadism,  masochism, 
bestiality  and  necrophilia. 

Masturbation  is  very  frequent  in  psychopaths. 
Often  appearing  very  early,  it  is  to  be  regarded  as  a 
sign  and  not  as  a  cause  of  degeneration,  though  in  all 
probability  it  accentuates  already  existing  defects. 

Fetichism  occurs  almost  exclusively  in  men;  it  is 
an  anomaly  in  which  sexual  excitement  and  some- 
times even  gratification  of  the  sexual  desire,  ac- 
companied by  ejaculation,  are  produced  by  the  sight 
or  contact  of  certain  objects,  or  of  certain  parts  of 
the  female  body  other  than  the  genital  organs. 

Fetiches  may  be  (a)  various  objects:  articles  of 
clothing  (gowns,  petticoats,  handkerchiefs),  toilet 
articles,  laces,  expensive  fabrics,  in  a  word,  all 
objects  used  by  women;  (/3)  parts  of  the  body:  the 
breasts,  the  hands,  the  feet,  the  hair.  Several 
fetiches  may  be  associated  in  the  mind  of  the  same 
patient. 

Moll  has  justly  remarked  that  the  mere  fact  that 
an  individual  has  a  predilection  for  some  portion  of 
the  female  body  does  not  in  itself  constitute  fetich- 
ism. ''One  may  like  by  preference  a  pretty  mouth, 
light  or  dark  hair,  or  large  eyes,  without  having  any 
genital  perversion."  Similarly  a  letter  or  an  object 
belonging  to  a  woman  may  produce  an  agreeable 
impression  by  the  recollections  which  it  gives  rise  to. 
An  anomaly  is  present  only  when  the  presence  or 
mental  representation  of  such  objects  is  in  itself 
efficient   and   provokes   sexual   excitement   without 


344  MANUAL  OF  PSYCHIATRY. 

giving  rise  to  any  recollection  of  any  particular 
woman. 

Fetichism  often  appears  at  the  time  when  nor- 
mally the  sexual  instinct  becomes  manifest.  The 
choice  of  the  fetich  depends  upon  the  impression 
which  is  accidentally  associated  with  the  first  genital 
excitement.  While  in  the  normal  individual  this 
accidental  association  leaves  no  trace,  in  the  fetichist 
the  impression  and  the  excitation  form  an  indissol- 
uble combination,  so  that  the  first  invariably  brings 
about  the  second. 

The  desire  to  possess  the  fetich  is  sometimes  so 
intense  as  to  lead  the  patient  to  thefts  or  to  various 
strange  acts.  One  patient  of  Vallon's  was  arrested 
while  cutting  bits  of  cloth  from  the  dresses  of  women 
who  were  with  him  at  the  time  in  a  newspaper 
office.  Most  of  the  so-called  hair  despoilers  are 
hair  fetichists. 

Exhibitionism  has  been  defined  elsewhere.^  It  may 
be  met  with  in  dements  and  in  epileptics,  and  often 
takes  the  form  of  an  impulsive  obsession. 

Sadism  consists  in  a  sense  of  voluptuousness  de- 
rived from  sufi"ering  which  the  patient  witnesses  or  in- 
flicts uj)on  his  victim.  This  sense  is  almost  always 
associated  with  a  state  of  genital  excitation.  As  is 
the  case  with  most  sexual  anomahes,  it  is  more 
frequent  in  men. 

History  contains  terrible  examples  of  sadism. 
Such  is  that  of  jMarshal  Gilles  de  Rays,  who,  during 
a   period    of   eight    years,    assassinated    over   eight 


1  See  Part  II,  Chapter  XXI. 


CONSTITUTIONAL  PSYCHOPATHS.  345 

hundred  children,^  subjecting  them  previously  to  de- 
filement and  torture.  The  exploits  of  the  too-well- 
known  Vacher  are  still  fresh  in  the  memories  of 
most  of  us. 

Sadism  is  exercised  chiefly  upon  women  and  upon 
children;  more  rarely  upon  animals. 

Many  sadists  content  themselves  with  simulation 
of  suffering  or  with  fictitious  humiliation  inflicted 
upon  their  pseudo-victim.  The  sadism  is  then 
symbolic  (Krafft-Ebing) . 

Masochism,  unlike  sadism,  is  more  frequent  in 
women.  It  consists  in  an  abnormal  pleasure  which 
the  subject  derives  from  his  or  her  own  suffering  or 
humihation.  To  this  category  belong  the  individuals 
who  request  women  to  strike  and  insult  them  and 
in  whom  sexual  excitation  cannot  be  produced 
otherwise. 

Bestiality  consists  in  an  impulse  to  copulate  with 
animals.  Like  all  genital  impulses  it  often  assumes 
the  shape  of  an  imperative  idea  which  the  subject 
can  in  some  cases  resist  by  an  effort  of  the  will  or  by 
various  curious  subterfuges.  Magnan  cites  a  case 
of  a  young  girl  who,  seized  with  the  idea  of  having 
connection  with  a  dog,  escaped  the  morbid  impulse 
by  turning  her  attention  to  another  animal. 

Necrophilia  is  the  rarest  of  all  forms  of  sexual 
perversion.  It  consists  in  a  particular  pleasure 
which  the  subject  experiences  from  the  sight  or  con- 
tact of  a  cadaver.  Often,  but  not  always,  this  is 
accompanied  by  an  impulse  to  defile  the  corpse. 

^  Quoted  by  Krafft-Ebing  from  Jacob,  the  historian. 


346  MANUAL  OF  PSYCHIATRY. 

(b)  Sexual  inversion  consists  in  a  contrast  existing 
between  the  physical  sex  and  the  psychic  sex:  the 
subject  presents  the  sexual  tendencies  of  the  opposite 
sex. 

Much  more  frequent  in  men  than  in  women, 
sexual  mversion  often,  but  not  always,  leads  to 
pederasty.  Sexual  inversion  is  always  congenital. 
The  anomaly  is  stamped  upon  the  entire  psychic  and 
even  physical  personality  of  the  subject. 

Many  of  these  individuals  have  the  character  and 
tastes  of  the  opposite  sex.  The  little  boy  plays  with 
dolls,  and  finds  pleasure  only  in  the  society  of  girls. 
Later  on  the  same  feminine  tendencies  persist,  and 
the  patient  secretly  abandons  himself  to  them.  We 
also  often  meet  with  men,  apparently  normal,  who 
in  their  privacy  dress  themselves  in  female  attire, 
cover  themselves  with  laces,  or  passionately  indulge 
in  feminine  emplopiients,  as  sewing,  embroider}^,  etc. 

Physically  certain  anomalies  are  noted  which  re- 
semble the  nonnal  characteristics  of  the  feminine 
organism:  considerable  development  of  the  breasts 
and  hips,  absence  of  the  beard,  rounded  shape  of  the 
neck,  etc.  Occasionally  we  observe  a  more  or  less 
marked  degree  of  pseudo-hermaphroditism.  ^ 

The  oj:)p()sito  anomalies  are  encountered  in  the 
female  sexual  invert :  masculine  features,  beard, 
masculine  v(jice,  etc. 

Some  in\'erts  may  have  nomial  sexual  intercourse, 
but  they  derive  no  satisfaction  from  it,  and  always 
feel  an  attraction  for  the  homologous  sex;  often 
they  marry,  hoping  thus  to  cure  their  infirmity,  but 
their  attempt  is  never  successful.  / 


CONSTITUTIONAL  PSYCHOPATHS.  347 

Obsessions.^  —  An  obsession  consists  in  an  im- 
perative idea  associated  with  a  state  of  anxiety,  there 
being  no  marked  disorder  of  consciousness  or  judg- 
ment. 

We  have  already  studied  imperative  ideas  and 
learned  that  they  constitute  a  form  of  mental 
automatism. 

We  have  also  studied  the  principal  characteristics 
of  anxiety.  Its  relations  to  imperative  ideas  have 
been  much  discussed.  Westphal,  who  was  one  of 
the  first  to  make  a  thorough  study  of  obsessions,  is 
of  the  opinion  that  the  anxiety  is  always  secondary 
to  the  imperative  idea.  This  opinion  is  certainly 
too  absolute,  for  anxiety  may  precede  the  impera- 
tive idea  and  even  appear  independently  of  it, 

Ribot,  Freud,  Pitres,  and  Regis  have  insisted  upon 
those  cases  of  diffuse  anxiety,  or  panophobia,  in 
which  the  emotion  exists  independently  of  any  fixed 
idea.  2 

This  question  seems  to  be  analogous  to  that  which 
we  have  considered  in  connection  with  allopsychic 
disorientation  and  hallucinations.  I  am  inclined 
in  this  case  to  \dew  with  favor  a  similar  solution, 
namely,  that  imperative  ideas  and  anxiety  are  two 


1  Arnaud.  Sur  la  Iheorie  de  V obsession.  Arch,  de  neurol.,  1902, 
No.  76.  —  Roubinowitch.  Elude  clinique  des  obsessions  et  des  im- 
pulsions morbides.  Ann.  med.  psych.,  Sept. -Oct.,  1899.  —  P.  Janet. 
Les  obsessions  et  Vanusthenie,  1902,  Paris,  F.  Alcan. 

2  Freud.  Obsessio?is  et  phobies.  Rev.  neurol.,  1895.  Manaud. 
L<i  nevrose  d'angoisse.  Troubles  nerveux  d'origlne  sexuelle.  These 
de  Lyon,  1900.  P.  Loade.  De  I'angoisse.  Rev.  de  m6d.,  1902, 
Aug. -Oct. 


348  MANUAL  OF  PSYCHIATRY. 

manifestations  of  the  same  fundamental  psychic 
disorder. 

Intact  consciousness  and  judgment  are,  as  we  have 
just  pointed  out,  the  rule  in  obsessions;  the  patient 
is  therefore  able  to  realize  the  pathological  nature  of 
his  phenomenon.  There  are,  however,  some  ex- 
ceptions to  this.  The  subject  has  sometimes,  when 
his  anxiety  reaches  its  height,  a  sense  of  a  reduplica- 
tion or  of  a  transformation  of  the  personality.  One 
such  patient  of  Seglas  entered  a  shop  "to  speak  to  the 
clerks,  to  ask  for  something  and  thus  to  find  new 
proof  that  she  was  her  real  self." 

Obsessions  are  occasionally  accompanied  by  hal- 
lucinations, chiefly  motor  hallucinations,  which  in  a 
manner  exteriorize  the  imperative  idea. 

Obsessions  are  of  various  forms.  First  of  all,  three 
great  classes  are  to  be  distinguished,  depending  upon 
the  influence  which  the  imperative  idea  exercises 
upon  the  patient:  (1)  intellectual  obsessions,  which 
are  unaccompanied  by  any  voluntary  activity; 
(2)  impulsive  obsessions,  in  which  the  idea  tends  to 
be  transformed  into  an  act;  (3)  inhibiting  obsessions, 
the  action  of  which  tends  to  paralyze  certain  volun- 
tary acts. 

(1)  Intellectual  obsessions.  —  The  consciousness  of 
the  patient  is  occuiHed  cither  by  some  concrete  idea, 
—  a  word,  an  object,  an  image  of  some  person  or  of 
some  scene,  —  or  ])y  some  abstract  idea,  often  of  a 
metaphysical  nature.  To  the  latter  catc^gory  l)elong 
the  obsessions  in  which  the  subject  has  a  feeling 
that  he  does  not  exist,  that  the  external  world  is 
formed   of   nothing   but   phantoms,   etc.     The   im- 


CONSTITUTIONAL  PSYCHOPATHS.  349 

perative  idea  is  then  said  to  have  a  negative  form. 
In  other  instances,  without  going  as  far  as  complete 
negation,  it  is  expressed  by  doubt,  thus  constituting 
a  transitional  form  between  intellectual  and  in- 
hibiting obsessions. 

(2)  Impulsive  obsessions.  —  These  are  very  numer- 
ous.    The  following  are  the  principal  forms: 

Onomatomania:  an  irresistible  desire  to  pronounce 
certain  words,  sometimes  obscene  words  (coprolaha). 
Associated  with  a  tic,  coprolalia  constitutes  the 
"disease  of  convulsive  tics"  (the  disease  of  Gilles 
de  la  Tourette). 

Arithmomania:  an  irresistible  desire  to  count 
certain  objects,  add  certain  figures,  etc. 

Kleptomania:  a  morbid  impulse  to  steal  objects 
which  are  entirely  useless,  or  which  the  subject  can 
easily  pay  for. 

Dipsomania:  an  irresistible  impulse  to  drink  alco- 
holic beverages  of  every  description  (wines,  liquors, 
eau-de-Cologne,  spirits  of  camphor,  etc.),  occurring 
in  a  person  of  temperate  habits,  who  may  at  other 
times  have  even  a  dislike  for  alcohol.  The  attacks 
may  recur,  and  the  dipsomaniac  may  become  an 
alcoholic.  He  differs  radically  from  the  ordinary 
drunkard,  however,  "The  one  is  alienated  before 
beginning  to  drink,  the  other  (the  alcoholic)  be- 
comes alienated  because  of  his  drinking"  (Magnan). 

Pyromania.  - —  Suicidal  and  homicidal  impulses}  — 
These  three  obsessions  are  of  equal  gravity  from  a 

1  Vallon.  Obsession  homicide.  Ann.  med.  psych.,  Jan. -Feb., 
1896.  —  Carrier.  Contribution  a  V etude  des  obsessions  et  des  impul- 
sions a  Vhomicide  et  an  suicide.     These  dc  Paris,  1900.  ■ 


350  MANUAL  OF  PSYCHIATRY. 

social  standpoint  and  may  be  placed  in  the  same 
group.  The  first  consists  in  a  morbid  impulse  to 
set  buildings  on  fire;  the  other  two  require  no  defini- 
tion. 

In  some  cases  the  patients  obey  their  fatal  im- 
pulses. Vallon  has  reported  a  case  of  a  young  man 
who,  having  a  homicidal  obsession,  struggled  against 
the  impulse,  but  was  finally  overcome  and  yielded. 

Such  cases,  however,  are  rare.  Usually  the 
patients  succeed  by  various,  and  at  times  singular, 
means  in  resisting  their  impulse.  Many  take  flight 
at  the  moment  of  the  paroxysm;  others  request  tc 
be  restrained  or  held;  still  others  voluntarily  have 
themselves  committed.  One  patient  of  Joffroy's, 
while  walking  in  the  street,  was  seized  with  the  idea 
of  tlirowing  her  child  under  the  wheels  of  a  passing 
car;  she  entered  a  wine  merchant's  shop,  placed  her 
child  upon  the  counter  and  took  flight. 

Similarly,  it  is  very  rare  for  patients  to  yield  to  a 
suicidal  impulse.  The  means  they  make  use  of  to 
escape  their  obsession  are  innumerable.  A  woman 
possessed  by  the  idea  of  throwing  herself  out  of  the 
window  had  all  the  windows  of  her  house  protected 
with  iron  bars.  Another  such  unfortunate  con- 
demned herself  never  to  cross  the  Seine  river  to  pre- 
vent herself  from  yielding  to  the  impulse  to  drown 
herself. 

As  to  family  suicide,  it  is  almost  never  the  result 
of  an  obsession,  but  of  a  fixed  idea  which  is  developed 
by  imitation. 

(3)  Inhibiting  obsessions.  —  Like  the  preceding 
ones,  these  assume  very  varied  forms. 


CONSTITUTIONAL  PSYCHOPATHS.  351 

One  of  the  most  frequent  is  the  "doubting  mania." 
Its  characteristic  feature  is  the  inability  on  the  part 
of  the  patient  to  affirm  a  fact  or  to  make  a  determi- 
nation. 

Many  normal  persons  experience  this  phenomenon 
in  a  slight  degree.  At  the  borderland  of  doubting 
mania  we  find  individuals  who  hesitate  before  mail- 
ing a  letter,  in  spite  of  having  already  several  times 
verified  the  contents,  the  address,  the  sealing  of  the 
envelope,  adherence  of  the  stamp,  etc. 

Doubt  is  likely  to  assume  the  form  of  scruples,  so 
frequent  in  religious  persons:  a  fear  of  profaning 
sacred  objects,  of  not  being  in  a  holy  state  of  mind, 
etc. 

Closely  related  to  doubting  mania  are  the  phobias, 
which  are  usually  groundless  and  sometimes  ridicu- 
lous; their  absurdity  is  recognized  by  the  subject 
himself. 

Some  patients  do  not  dare  to  touch  any  object, 
constantly  wear  gloves,  wash  their  hands  a  hundred 
times  daily,  etc.  This  phobia,  which  includes  also 
the  fear  of  contracting  an  infectious  disease  through 
contact  with  contaminated  articles  (nosophobia),  con- 
stitutes the  "delire  du  toucher." 

Others  have  a  fear  of  being  unable  to  stand  up  or 
to  accomplish  certain  movements,  such  as  walking. 
''In  a  deserted  place,  in  a  very  wide  street,  upon  a 
bridge,  in  a  church,  or  in  a  theater  the  patient  is  sud- 
denly seized  with  the  idea  that  he  will  be  unable  to 
cross  the  wide  space  before  him,  that  he  is  going  to 
die,  or  that  he  is  going  to  be  sick."^ 

1  R^gis.     Manuel  'pratique  de  Medecine  mentale,  p.  279. 


352  MANUAL  OF  PSYCHIATRY. 

This  morbid  phenomenon,  known  as  agoraphobia, 
induces  a  veritable  functional  paralysis,  and  the 
patient  may  fall  if  he  is  not  supported.  The  shghtest 
support  is  sufficient  to  calm  and  reassure  him;  the 
origin  of  the  attack  is,  therefore,  purely  psychic 

Claustrophobia  is  the  opposite  of  agoraphobia;  it 
consists  in  an  inability  on  the  part  of  the  patient  to 
remain  in  a  closed  space. 

Erythrophobia,  first  described  by  Pitres  and  Regis, 
consists  in  a  fear  of  blushing.  These  patients  do  not 
dare  to  attract  anybody's  attention  to  themselves^ 
being  sure  to  blush  most  distressingly.  This  phobia 
is  closely  related  to  ordinary  timidity,  of  which  it  is 
occasionally  a  complication. 

The  following  case  shows  a  state  of  panophobia  or 
diffuse  anxiety  combined  with  very  pronounced  doubt- 
ing mania,  manifesting  itself  by  constant  uncer- 
tainty and  by  moral  and  religious  scruples.  To  use 
the  very  expressive  terminology  of  Freud,  the  patient 
is  in  a  state  of  permanent  anxious  anticipation  which, 
at  the  occasion  of  the  most  immaterial  and  trifling 
occurrences,  develops  into  an  attack  of  anxiety. 

Miss  Margaret  F.,  forty-three  years  of  age,  private  teacher. 
Family  history:  father  alcohoUc.  The  patient  is  of  normal  intelli- 
gence. Disposition  melancholy,  but  gentle  and  affectionate.  The 
patient  lived  for  twelve  years  with  the  same  family,  where  she  had 
inspired  a  true  attachment  for  herself.  She  has  had  no  serious 
illnesses,  save  frequent  attacks  of  migraine. 

The  onset  of  the  illness  dates  back  to  the  fall  of  1903.  The 
young  lady  whom  she  had  been  teaching  finished  her  education, 
and  Miss  F.  hat!  to  take  another  position.  This  grieved  her  very 
much.  She  gradually  grew  .sad,  depressed,  and  b(>came  disgusted 
with  everything.  In  Novonhcr,  1(K)3  (seven  months  after  her 
change  of  po.sition),  she  began  to  have  all  kinds  of  doubts:    Has 


CONSTITUTIONAL  PSYCHOPATHS.  353 

she  said  her  prayers  properly?  Has  she  not  made  a  mistake  in 
asking  the  druggist  for  medicine?  Feeling  herself  to  be  really  ill 
she  left  her  new  position  and  went  home  to  her  parents.  Her 
morbid  preoccujjations,  however,  persisted.  Her  general  health 
was  not  very  good.  She  lost  considerable  flesh  in  a  short  time. 
She  was  taken  to  a  sanitarium  on  January  4,  1904. 

An  examination  made  on  that  day  showed  the  following:  Stature 
slightly  below  the  medium.  Constitution  normal.  No  evident 
organic  disease  except  a  slight  degree  of  emaciation.  Lucidity 
perfect.  Patient  had  a  very  clear  reahzation  of  her  own  condi- 
tion. She  showed  uneasiness  with  continuous  agitation:  walked 
up  and  down  the  room,  shifted  from  one  foot  to  the  other,  rubbed 
her  hands  in  a  nervous  manner,  looked  around  with  a  sort  of  appre- 
hension, doing  all  this,  she  said,  in  spite  of  herseK  and  without 
any  definite  idea.  A  few  moments  after  her  arrival  doubts  and 
fears  made  their  appearance.  She  noticed  a  bottle  of  syrup  on 
a  table  in  her  room.  Immediately  she  be^an  to  wonder  if  she 
had  not,  without  knowing  it,  poured  sopiething  into  the  bottle, 
perhaps  poison,  or  ink,  or  perfume.  Later  on  the  same  day,  also 
on  the  days  which  followed,  new  fears  developed  and  the  doubts 
increased.  The  following  is  a  transcript  of  some  of  the  case  notes 
from  the  records  of  this  patient. 

January  15.  Patient,  on  receiving  her  mail,  could  not  make  up 
her  mind  to  open  it.  The  nurse  opened  it  for  her.  The  patient 
is  afraid  to  sort  her  own  linen  or  clothing.  She  begs  the  nurse  to 
examine  minutely  every  piece  and  to  take  her  oath  that  no  injuri- 
ous powder  has  been  found  on  the  fabrics  or  on  the  bed  linen. 
She  knew  that  she  had  on  her  arrival  at  the  sanitarium  121  fr.  75 
cms.  in  her  pocket-book,  in  fact  she  had  written  the  amount  down 
in  her  note  book,  yet  she  was  in  doubt.  She  had  the  nurse  count 
the  money  over  and  finally,  still  doubting,  decided  to  write  to  her 
mother  asking  whether  this  was  the  correct  amount.  In  the  eve- 
ning she  said  her  prayers,  kneeling  at  the  bedside,  but  insisted  on 
a  nurse  being  present  all  the  time  in  order  that  she  might  have 
proof  later  on  that  she  said  her  prayers  properly. 

January  17.  Patient  went  to  mass  and  had  prepared  three 
10-centime  pieces  for  the  collection.  But,  contrary  to  her  expec- 
tation, the  collection  tray  went  around  only  twice;  there  remained, 
therefore,  one  10-centime  piece.  She  passed  the  entire  day  in  most 
painful  anxiety,  not  knowing  what  to  do  with  the  ten  centimes, 
asking  herself  whether  they  were,  really  hers,  or  whether  she  had 


354  MANUAL  OF  PSYCHIATRY. 

inadvertently  taken  them  from  the  collection  tray,  or  picked  them 
up  from  a  neighboring  seat. 

January  23.  Patient  fears  she  was  disrespectful  in  her  remarks 
to  the  physician.  Thi.s  is  jirobably  due  to  her  being  neglected, 
because  no  attention  i.s  paid  to  her  complaints.  But  it  is  also  her 
own  fault  that  she  is  left  to  herself:  perhaps  she  has  not  followed 
the  doctor's  advice,  as  she  should  have  done.  If  one  could  only 
return  the  jiast!  It  may  be,  too,  that  she  hjis  not  always  done  her 
duty  toward  her  relatives;  in  that  case  her  sufTerings  are  but  the 
punishment  of  heaven.  On  close  inquiry  it  is  found  that  the 
patient  has  no  true  self-accusations;  the  i)atient  herself  says  that 
there  is  no  real  foundation  for  these  ideas,  but  that  they  just  force 
themselves  upon  her  mind. 

January  29.  The  patient  was  seized  with  fear  at  the  idea  of 
going  up  to  her  room  alone  to  find  a  handkerchief.  A  nurse  had  to 
accompany  her. 

February  9.  Patient  decided  to  go  out  for  a  walk  in  the  park; 
all  the  time  she  insisted  on  holding  the  nurse's  hand,  and  still  had 
to  come  back  after  a  few  minutes  because,  she  said,  she  was  very 
much  afraid.  "Afraid  of  what?"  the  nurse  asked  her.  "I  don't 
know.  .  .  .  Has  there  not  been  an  accident  or  a  crime  in  the 
park  several  days  ago?"  In  spite  of  all  a-ssurance  on  the  part  of 
the  nurse  that  nothing  unusual  had  happened  the  patient  could 
not  be  calmed  l)ut  kept  asking  the  physician,  his  assistant,  and  the 
nurse  the  same  question  over  and  over  again. 

February  15.  At  the  table  the  nurse  emptied  a  package  of 
vichy  salt  into  a  glass  of  water.  The  patient  was  seized  with  great 
terror.  "What  was  that  white  powder?"  Vichy  salt,  they  told 
her.  "But  has  there  not  been  some  mistake?  Is  it  not  some  kind 
of  poison?  Have  not  some  particles  of  it  fallen  on  my  plate?" 
Everybody  jjrcsent  a.ssunHl  her  that  she  had  no  reason  to  be 
alarmed,  that  no  mistake  was  possilile,  that  at  any  rate  her  plate 
was  too  far  for  any  particles  from  the  package  to  have  fallen  on  it, 
but  all  to  no  ])urp()se;  the  entire  lunch(X)n  hour  and  the  rest  of  the 
afternoon  was  i)assed  ])y  the  patient  in  the  same  state  of  anxiety. 

February  25.  Patient  wanted  to  have  all  the  salt  cellars  on  the 
table  emptied  Jis  they  might  contain  something  injurious. 

February  26.  Somebody,  in  relating  a  piece  of  news  from  the 
pai)er,  made  use  of  the  word  "accident."  The  patient  uttered  a 
cry.  That  was  horrible,  she  declared,  such  words  ought  not  to  be 
uttered  in  her  presence,  they  cause  her  such  fear.     Later  it  appeared 


CONSTITUTIONAL  PSYCHOPATHS.  355 

that  there  was  a  whole  list  of  words  that  she  ought  never  to  hear: 
crime,  poison,  death,  thief,  sanitarium,  asylum,  etc. 

March  2.  Patient  was  visited  by  a  friend.  She  seemed  to 
derive  no  pleasure  from  the  visit,  cried  a  great  deal,  and  took  no 
interest  in  the  news  her  friend  told  her.  At  the  supper  table  she 
suddenly  remembered  that  it  was  a  fast  day  and  refused  to  eat 
any  meat.  She  was  offered  some  eggs,  but  hesitated  a  good  half 
hour  before  accepting  them.  For  her  salvation  she  ought  to  be 
content  with  some  peas.  On  the  other  hand,  the  doctor  told 
her  to  eat  meat,  which,  in  fact,  would  be  better  for  her  health. 
Further,  by  taking  the  eggs  would  she  not  be  depriving  someone? 
Finally  she  decided,  or  rather  it  was  decided  for  her,  to  have  two 
boiled  eggs.  But  she  did  not  cease  worrying  and  during  the  entire 
evening  kept  asking  herself  what  she  ought  best  to  have  done. 

March  21.  The  patient  was  informed  that  her  relatives  had 
decided  to  take  her  home,  which  she  had  several  times  begged 
them  to  do.  Instead  of  being  pleased  she  became  despondent. 
This  may  not  be  prudent,  she  is  not  yet  cured,  who  will  take  care 
of  her  at  home? 

On  the  following  day  she  was  discharged  from  the  sanitarium, 
unimproved. 

Etiology.  —  The  etiology  of  obsessions  comprises 
two  principal  factors:  neuropathic  heredity  and 
general  asthenia  of  the  organism.  Thus  we  find  in 
most  of  the  victims  of  obsessions  a  more  or  less 
charged  heredity  associated  with  the  action  of  de- 
bilitating causes,  such  as  physical  or  mental  over- 
work, pregnancy,  lactation,  abundant  and  repeated 
hemorrhages. 

Treatment.  —  The  physical  treatment  consists 
chiefly  in  rest,  outdoor  life,  reconstructive  diet;  the 
psychic  treatment  consists  in  hypnotic  or  simple  sug- 
gestion. Simple  suggestion  is  the  preferable  method 
of  the  two,  as  these  patients  usually  derive  Httle 
benefit  from  hypnotism. 


356  MANUAL  OF  PSYCHIATRY. 

§  3.   MoKAL  Insanity. 

By  reason  of  its  complexity  the  moral  sense  is  one 
of  the  most  delicate  and  most  vulnerable  functions 
of  the  mind.  Thus  we  find  it  altered  in  most  of 
the  psychoses,  especially  in  those  accompanied  by 
intellectual  enfeeblement. 

The  symptoms  to  which  alterations  in  the  moral 
sense  give  rise  do  not  merit  the  name  of  moral  in- 
sanity unless  they  exist  in  an  isolated  state  or  at  least 
are  not  associated  with  any  other  apparent  mental 
disorder.  I  say  apparent,  because  close  observation 
almost  always  reveals  the  existence  in  the  subject  of 
certain  peculiarities  which  show  that  the  anomaly 
extends  beyond  the  moral  sphere. 

Moral  insanity  finds  early  expression  in  perver- 
sities of  the  character  and  conduct.  The  child  is 
naughty,  cruel,  deceitful,  irritable,  violent;  or  he  is, 
on  the  contrary,  taciturn  and  dissembling. 

Education  totally  fails  to  modify  such  natures. 
The  moral  sense  is  not  built  up  upon  notions  ac- 
quired through  intellectual  culture.  It  is  the  result 
of  a  special  sensibility,  of  a  function  which  the 
psychic  organ  lacks  in  moral  insanity.  "WTien  this 
apparatus  is  absent,  the  most  favorable  surround- 
ings fail  to  exert  their  influence."^ 

As  the  child  becomes  a  man,  as  he  comes  into 
more  direct  contact  with  society,  his  infirmity  be- 
comes more  manifest. 


'  IMeulcr.     Der  gcborcne  Vcrbrechcr.     Eine  kritische  Studie,  1896, 
p.  21. 


MORAL  INSANITY.  357 

The  dominant  feature  of  moral  insanity  is  pro- 
found egoism  combined  with  complete  indifference 
with  regard  to  good  and  evil. 

The  exclusive  aim  of  such  an  individual  is  his 
pleasure  or  his  own  interest  (and  very  often  he  has 
but  poor  judgment  as  regards  even  his  own  interest), 
and  to  reach  this  aim  he  does  not  hesitate  to  use  any 
means  or  any  expedient.  He  has  neither  sentiment 
of  honor  nor  respect  for  the  truth.  His  unique  pre- 
occupation is  to  escape  conviction  and  punishment. 

Cruel  and  malicious  toward  his  inferiors  and 
toward  the  weak  in  general,  he  is  cowardly  toward 
anybody  who  is  above  him.  In  the  asylum  or  prison 
he  quite  readily  submits  to  the  rules  and  to  the 
discipline  and  does  not  abandon  himself  to  his 
morbid  propensities  until  he  regains  his  liberty. 

Undoubtedly  there  are  cases  of  moral  insanity  with 
a  sane  judgment  and  a  strong  will.  These,  freed 
from  the  scruples  which  might  interfere  with  their 
liberty  of  action,  occasionally  have  a  brilliant  career. 

Almost  always,  however,  other  psychic  anomalies 
are  present  in  addition  to  the  disorders  of  the  moral 
sphere.     The  most  frequent  are: 

(a)  Weakness  of  judgment:  the  subject  realizes  but 
imperfectly  the  possible  consequences  of  his  acts, 
and  in  spite  of  all  his  precautions  he  ultimately 
comes  into  conflict  with  the  law.  The  thoughtless- 
ness of  criminals  is  well  known. 

(b)  Absence  of  perseverance:  this  prevents  the 
utilization  of  any  aptitudes  which  the  patient  may 
possess  and  which  are  in  some  instances  very  con- 
siderable. 


358  MANUAL  OF  PSYCHIATRY. 

(c)  Impulsiveness:  the  moral  insane  readily  yield 
to  the  first  impulse,  so  that  it  is  quite  difficult  in 
practice  to  distinguish  them  from  the  impulsive 
criminals.  The  best  criterion  is  the  existence  of 
subsequent  remorse  in  the  latter.  Unfortunately,  it 
is  impossible  to  determinate  its  true  degree  of  sin- 
cerity. It  is  well  known  with  what  consummate  art 
hardened  criminals  simulate  the  most  touching 
remorse. 

(d)  Diverse  psychic  anomalies:  obsessions,  morbid 
emotionalism,  etc. 

*  Commitment  is  in  most   cases  necessary.     Agri- 

cultural colonies,  properly  conducted,  are  admirably 
suited  for  this  class  of  patients. 


CHAPTER  VIII. 

HUNTINGTON'S  CHOREA. 

Huntington's  chorea,  a  constitutional  affection 
in  the  strictest  sense,  occurring  on  a  hereditary  basis, 
forms  a  group  apart  from  and  apparently  entirely 
independent  of  the  other  constitutional  disorders 
thus  far  considered.  Arrests  of  development,  epi- 
lepsy, dementia  prsecox,  paranoia,  manic-depressive 
psychoses,  involutional  melancholia,  hysteria,  and 
allied  conditions  often  enough  present  a  history  of 
similar  ■  heredity,  but  at  least  as  often,  if  not  more 
so,  they  present  a  history  of  dissimilar  heredity,  so 
that  we  find  instances  of  two  or  more  of  them  exist- 
ing in  the  same  family.  For  this  reason  it  is  gener- 
ally held  that  these  conditions,  though  forming 
cUnically  fairly  distinct  entities,  are  nevertheless  in 
some  manner  related,  to  each  other.  The  case  is 
different  with  Huntington's  chorea.  In  all  cases  in 
which  a  complete  family  history  has  been  secured 
the  heredity  which  was  found  has  been  similar.  In- 
stances of  other  neuropathic  conditions  are,  indeed, 
occasionally  observed  in  the  famUies  of  patients 
suffering  from  Huntington's  chorea,  but  they  are 
relatively  so  infrequent  as  to  be  readily  accounted 
for  as  coincidences  essentially  without  relationship 
to  the  chorea  itself. 

Another   reason    for    assigning    to    Huntington's 

359 


360  MANUAL  OF  PSYCHIATRY. 

chorea  an  independent  position  among  the  constitu- 
tional disorders  is  the  special  manner  in  which  it  is 
transmitted  by  heredity.  Such  evidence  as  is  avail- 
able indicates  that  the  neuropathic  conditions 
enumerated  above  are  transmitted  in  the  manner  of 
Mendelian  recessives.  (See  Part  I,  Chapter  I, 
Etiology.)  Theoretically,  then,  the  development  of 
a  case  requires  a  convergent  heredity,  and  in  practice 
such  heredity  is  very  frequently  found  where  a 
complete  family  history  is  available;  furthermore, 
the  hypothesis  of  recessiveness  offers  an  explanation 
of  the  frequently  observed  fact  of  atavistic  heredity 
in  connection  with  cases  of  these  conditions.  Pedi- 
grees in  cases  of  Huntington's  chorea  practically 
never  show  either  convergent  or  atavistic  heredity; 
even  in  families  heavily  charged  with  this  condition 
an  individual  who  happens  to  be  free  from  it  is  also 
free  from  the  risk  of  transmitting  it  to  his  offspring; 
in  other  words  this  disease  does  not  skip  a  generation 
as  other  neuropathic  conditions  frequently  do. 
Thus  Huntington's  chorea,  considered  as  a  biologic 
trait,  behaves,  unlike  the  large  general  group  of 
other  neuropathic  conditions,  not  as  a  Mendelian 
recessive,  but  as  a  dominant  in  relation  to  the  normal 
condition.^ 

The  disease  is  comparatively  rare,  yet  most  insti- 
tutions for  the  insane  can  show  one  or  more  cases. 
Both  sexes  are  about  equally  affected.  The  age  of 
onset  in  typical  cases  is  between  thirty-five  and  fifty. 


'  C.    B.    Davenport.     Heredity   in   Relation   to  Eugenics.     New 
York,  1911.     P.  102. 


HUNTINGTON'S  CHOREA.  361 

The  development  is  gradual,  beginning  with  slight 
irregular  movements  of  the  face  and  upper  extremi- 
ties which  extend  slowly  over  the  rest  of  the  body, 
at  the  same  time  becoming  more  severe;  the  move- 
ments are  almost  constant,  ceasing  only  during  sleep; 
the  patient's  speech  becomes  affected,  eventually 
growing  indistinct  and  unintelligible.  There  are  no 
disturbances  of  sensation.  Mental  symptoms  appear 
in  almost  every  case  sooner  or  later;  "a,  weakness  of 
judgment  and  initiative,  absent-mindedness,  general 
dissatisfaction  with  surroundings,  a  growing  selfish- 
ness and  irritability  are  among  the  earliest  symptoms 
observed."  ^  The  fully  developed  mental  picture  is 
characterized  by  marked  irritability,  ideas  of  perse- 
cution, and  a  slow  but  progressive  deterioration;  the 
latter  consists  mainly  in  a  '^  disinclination  toward 
mental  exertion,  which  is  so  pronounced  that  the 
examination  becomes  very  difficult;  in  the  marked 
cases  it  interferes  even  with  such  simple  reactions  as 
stating  whether  it  is  summer  or  winter,  and  seems  to 
give  rise  to  the  fact  that  the  patient  does  not  respond 
at  all,  or  responds  in  a  perse veratory  manner ;  in  the 
milder  cases  it  shows  itself  in  calculation,  in  giving 
time  relations,  and  in  giving  the  substance  of  a  simple 
story  read  to  them,  leading  to  the  excuse  that  the 
memory  is  bad,  that  they  are  unable  to  tell  it,  etc.; 
whereas,  on  the  other  hand,  in  the  orientation,  even 
in  the  worst  cases,  there  is  remarkably  little  inter- 
ference; the  memory  of  actual  facts,  if  sufficiently 


^  A.  S.  Hamilton.     A  Report  of  Tiventy-sevcn  Cases  of  Chronic 
Progressive  Chorea.     Amer.  Journ.  of  Insanity,  Jan.,  1908. 


362  MANUAL  OF  PSYCHIATRY. 

insisted  upon,  is  found  to  be  quite  good."  ^  In  the 
original  description  of  the  disease  Huntington  men- 
tioned marked  suicidal  tendency  as  being  very  com- 
mon,^  and  this  observation  has  been  corroborated 
by  most  of  the  later  writers. 

Huntington's  chorea  is  a  chronic,  slowly  progres- 
sive, incurable  affection.  It  cannot  be  said  to  be  in 
itself  fatal,  death  usually  occurring  at  the  end  of 
many  years  from  some  intercurrent  disease. 

While  the  majority  of  cases  correspond  fairly 
closely  to  the  above  description,  more  or  less  marked 
variations  from  the  most  common  type  are  frequently 
seen.  The  onset  may  occur  at  an  early  age,  even  in 
childhood  or  in  infancy,  or  later  than  usual,  in  ad- 
vanced senility;  the  symptoms  may  be  mild,  con- 
sisting of  slight  movements,  limited  in  distribution, 
and  unaccompanied  by  any  mental  disorder;  or  the 
mental  deterioration  may  be  particularly  severe  and 
set  in  long  before  the  choreic  movements  develop.^ 

The  anatomical  changes  found  post  mortem  con- 
sist mainly  of  brain  atrophy,  shrinkage  of  cortical 
cells  with  dilatation  of  peri-cellular  spaces,  and  occa- 
sionally internal  hemorrhagic  pachymeningitis. 

'  W.  G.  Ryon.  A  Study  of  the  Deterioration  Accompanying 
Huntington^  Chorea.     N.  Y.  State  IIosp.  Bulletin,  Feb.,  1913. 

2  Georpe  IIuntintz;t()n.  On  Chorea.  The  Med.  and  Surg.  Re- 
porter, Apr.  13,  1872. 

'  C.  B.  Davenport.  Huntington's  Chorea  in  Relation  to  Heredity 
and  Eugenics.  Proc.  of  the  National  Academy  of  Sciences,  Vol. 
I,  p.  283,  May,  1915. 


CHAPTER  IX. 

ACUTE  ALCOHOLISM;  PATHOLOGICAL  DRUNKENNESS. 

The  term  drunkenness  is  here  used  to  designate  the 
nervous  and  mental  symptoms  by  which  acute  alcoholic 
intoxication  manifests  itself. 

The  predisposition  to  the  state  of  drunkenness,  quite 
variable  in  different  subjects,  is  a  part  of  the  general 
tendency  of  the  individual  toward  nervous  and  mental 
disorders.  "  It  may  be  truly  said  that  alcohol  is  the 
touchstone  of  the  equilibrium  of  the  cerebral  functions."* 

*  Fere.  La  Famille  nhrro-pathique.  Paris.  F.  Alcan. —  [This  state- 
ment is  correct,  everything  else  being  equal.  But  it  must  be  borne  in 
mind  that  there  are  other  factors,  besides  mental  instability,  that 
have  to  do  with  an  individual's  susceptibility  to  alcohol.  Age  is 
one  such  factor,  young  persons  being  more  susceptible  than  middle 
aged  or  old  ones.  But  by  far  the  most  important  factor  is  habit. 
We  know  well  that  it  is  not  uncommon  for  morphine  habitues,  who 
have  gradually  acquired  a  tolerance  for  that  drug,  to  take  as  much 
as  twenty  grains  at  a  dose  with  no  other  than  a  mild  euphoric  effect, 
whereas  one-fortieth  of  this  dose  produces  profound  sleep  in  an 
ordinary  person,  and  one-tenth  may  readily  prove  fatal.  We  know 
also  that  the  same  kind  of  tolerance  can  be  acquired  for  arsenic  and 
for  many  other  poisons,  and,  in  fact,  we  often  utilize  this  very  prin- 
ciple in  the  artificial  production  of  immvmity  against  certain  micn>- 
bic  toxines,  such  as  those  of  diphtheria  and  tetanus.  It  is  imdoubt- 
edly  so  also  in  the  case  of  alcohol,  for  it  is  on  the  basis  of  such  an 
acquired  tolerance  that  chronic  alcoholics  universally  boast  of  being 
able  to  "stand  any  amount"  or  at  least  of  being  "always  able  to 
navigate."] 

363 


364  MANUAL  OF  PSYCHIATRY. 

I  have  now  under  observation  an  imbecile  whom  a 
single  glass  of  wine  suffices  to  make  drunk. 

Drunkenness  is  somewhat  schematically  divided  into 
two  stages:  (1)  excitement,  and  (2)  paralysis.  In  re- 
aUty  paralysis  is  present  from  the  beginning,  but  in 
the  first  stage  it  is  limited  to  the  highest  psychic  func- 
tions and  is  masked  by  the  intensity  of  the  automatic 
phenomena,  so  that  it  does  not  become  evident  until 
the  second  stage,  when  all  the  nervous  and  mental 
functions  become  involved  in  the  paralysis. 

First  Stage :  Excitement.  —  Psychic  inhibition,  the  first 
manifestation  of  the  paralysis,  is  seen  in  the  slow  asso- 
ciation of  ideas,  the  distractibility,  and  the  insuffi- 
ciency of  perception.^  The  automatism  is  apparent 
from  the  disconnected  conversation,  which  may  show 
a  true  flight  of  ideas,  the  abnormal  pressure  of 
acti\dty,  the  more  or  less  marked  morbid  euphoria  and 
irritability,  the  impulsive  character  of  the  reactions, 
and  the  extremely  voluble  speech.  The  moral  sense 
and  the  regard  for  conuuon  conventionalities  gradu- 
ally disappear,  and  the  patient  may  commit  ridiculous, 
repugnant,  offensive,  or  even  criminal  acts. 

Second  Stage :  Paralysis.  —  Paralysis,  confined  in  the 
preceding  stage  to  the  sphere  of  the  higher  psychic 
functions,  now  attacks  the  automatic  functions.  The 
movements  are  awkward  and  clumsy,  the  speech  indis- 
tinct, the  gait  unsteady.  Gradually  the  patient  falls 
into  a  profound,  sometimes  comatose,  sleep,  — -the  final 
stage  of  the  attack,  —  from  which  he  awakes  lucid  but 

'  Ri'ulin.  AnlJaJisung  u»<}  Mrrk/dJiiykeit  u/itcr  AlkoJiohnrkung. 
Kra'fK'lins  Psycholog.  Arbeiten,  Vol.  IV,  No.  3. 


ACUTE  ALCOHOLISM.  365 

with  a  confused  recollection  of  what  has  passed  and  with 
a  pronounced  sensation  of  mental  and  physical  fatigue. 

Such  is,  rapidly  sketched,  the  aspect  of  common 
drunkenness.  From  the  accentuation  or  obUteration  of 
certain  features  result  the  diverse  abnormal  or  patho- 
logical forms. 

Comatose  drunkenness.  —  The  phenomena  of  excite- 
ment are  either  absent  or  very  transient.  From  the 
beginning  the  paralysis  affects  the  entire  brain.  The 
patient  sinks  and  remains  inert  and  insensible  for 
several  hours.  His  face  is  congested.  Gradually  the 
comatose  state  is  replaced  by  sleep,  from  which  the 
patient  awakes  without  any  recollection  whatever  of 
the  occurrences  immediately  preceding  his  intoxica- 
tion. Sometimes  the  pulse  becomes  small,  the  heart 
weak,  the  breathing  labored,  and  in  some  cases,  which 
are  fortunately  rare,  the  patient  dies  in  collapse. 

Maniacal  drunkenness.  —  Here  paralysis  occupies 
a  secondary  position  and  excitement  dominates  the 
scene.  The  phenomena  of  agitation  generally  develop 
ver}'-  rapidly.  All  of  a  sudden  the  drunkard,  while  still 
at  the  saloon-keeper's  bar,  is  seized  with  an  outbreak 
of  furious  madness  without  any  apparent  cause  or 
provocation;  he  breaks  objects  and  furniture,  becomes 
noisy,  and  threatens  and  attacks  those  about  him. 
The  extreme  clouding  of  the  intellect  shows  that,  in  spite 
of  appearances,  "  psychic  activity  takes  but  a  very- 
small  part  in  the  production  of  the  outbreak,"  and 
that  "  subjugated  by  this  automatic  development  of 
psycho-motor  acti\'ity  it  disappears  entirely."  ^     Almost 

*  Gamier,     La  folie  a  Paris. 


366  MANUAL  OF  PSYCHIATRY. 

always  numerous  psycho-sensory  disorders  (hallucina- 
tions and  illusions)  are  associated  with  the  clouding 
of  the  intellect  and  the  excitement. 

The  attack  terminates  in  profound  sleep.  This,  as 
in  the  preceding  form,  is  followed  by  almost  complete 
amnesia. 

Convulsive  drunkenness. — The  maniacal  form  of 
drunkenness  resembles  closely  the  delirious  attacks  of 
epilepsy.  The  relation  between  epilepsy  and  acute 
alcoholic  intoxication  appears  still  closer  when  we 
consider  that  drunkenness  may  cHnically  assume 
the  aspect  of  an  epileptic  seizure.  This  is  explained 
by  the  convulsive  properties  of  alcohol,  which  have 
been  demonstrated  experimentally.  Attacks  precisely 
like  those  of  essential  epilepsy  may  supervene  in  the 
course  of  common  drunkenness.  In  all  cases  they 
immediately  follow  the  alcoholic  excesses,  differing  in 
this  respect  from  those  epileptiform  seizures  which 
supervene  in  the  course  of  chronic  alcoholism. 

Delusional  drunkenness.  —  This  curious  but  rare  form 
has  been  well  studied  by  Garnier.  The  delusions  are 
extremely  variable:  ideas  of  persecution,  ambitious 
ideas,  depressive  ideas  with  suicidal  tendencies,  etc. 
Delusional  drunkenness  is  encountered  only  in  pro- 
foundly neuropathic  individuals. 

Pathological  anatomy. —  The  lesions  of  acute  alcohohc 
intoxication  liave  boon  studied  cliiefly  in  animals 
poisoned  expcrimontally.  Macroscopically  there  are 
conjestion  and  sub-j)ial  honiorrhages.  M i(roscopicaHy 
are  found,  in  addition  to  engorgement  and  distension 
of  the  blood-vessels,  nerve  cell  changes  consisting 
principally   in    swelling   of    the    nuclei    and    peripheral 


ACUTE  ALCOHOLISM.  367 

chromatolysis.  These  lesions  are  most  marked  in  the 
motor  cells  of  the  spinal  cord,  but  they  exist  also, 
though  less  pronounced,  in  the  cells  of  the  cortex.  ^ 
Treatment.  —  This  of  course  varies  with  the  different 
forms.  Maniacal  or  delusional  drunkenness  requires 
strict  watching  and  immediate  isolation;  the  comatose 
form  requires  the  use  of  external  and  internal  stimu- 
lation (friction,  ammonium,  ether,  caffein). 

'  Marinesco.     Semaine  medicale,  June  14,  1899. 


CHAPTER  X. 

CHRONIC  ALCOHOLISM. 

Chronic  alcoholism  manifests  itself:  (1)  in  per- 
manent symptoms  (the  chronic  stigmata  of  alcoholism), 
and  (2)  in  episodic  accidents. 

I.  Permanent  Symptoms. 
The  permanent  symptoms  are  psychic  and  physical. 

A.    PSYCHIC    SYMPTOMS. 

There  is  enfecblement  of  all  the  i)sycliic  functions. 

Intellectual  sphere. — InteUectual\adivity  and  capacity 
for  work  are  (Hminished.  The  patient  be(;omes  dull, 
negligent,  and  clumsy. 

The  disorders  of  memory  consist  in  definite  retro- 
grade amnexia  by  destru(;tion  of  imj)r('ssi()ns,  associated 
with  more  or  less  marked  cmtcrogracle  amnesia.  The 
former  follows  tlie  general  law  of  amnesia.  Its  course 
is  slowly  j)rogressive;  but  it  is  rare  for  it  to  I'cacli  as 
complete  a  dev('loi)ment  as  it  does  in  general  paresis. 
Tlie  antei'ograde  amnesia  renders  it  diflicult  oi-  (n'en 
im])Ossible  for  the  ])atient  to  accjuii-e  new  impr(>ssions; 
thus  the  stuck  of  ideas  becomes  more  and  more  inn)over- 

ished. 

368 


CHRONIC  ALCOHOLISM.  369 

The  judgment  is  constantly  affected:  the  patient 
realizes  but  imperfectly  his  condition  and  the  importance 
and  significance  of  his  acts. 

Emotional  sphere.  —  As  in  most  affections  with  a 
basis  of  intellectual  enfeeblement,  we  find  in  chronic 
alcoholism  indifference  associated  with  morbid  irrita- 
bility. 

The  chronic  alcoholic  is  not  at  all  concerned  with 
his  ruined  business,  the  misery  of  his  family,  or  the 
compromise  of  his  honor.  Only  the  desire  for  alcohol 
can  still  arouse  him  from  his  mental  torpor.  The 
atrophy  of  the  moral  sense,  which  in  these  cases  goes 
hand  in  hand  with  the  general  indifference,  is  such  that 
in  order  to  procure  his  favorite  drinks  the  patient  does 
not  hesitate  to  make  use  of  the  most  unscrupulous  means 
and  to  associate  with  the  vilest  characters.  If  he  still 
works,  he  spends  his  earnings  on  drink.  If  he  does 
not  work,  as  is  the  rule  in  such  cases,  he  accumu- 
lates debts  in  the  lowest  drinking-dens,  extorts  from 
his  relatives  what  little  money  they  may  have  earned 
by  hard  labor,  and  he  may  even  resort  to  steaHng. 

The  irritability  and  the  impulsive  tendencies  give  rise 
to  \'iolent,  terrible  outbursts  of  anger,  and  often  to 
assaults  and  attempts  at  murder. 

Delusions  may  appear  at  times,  almost  always  those 
of  persecution  or  of  morbid  jealousy.  When  they 
become  more  developed  and  acquire  a  certain  fixedness 
they  constitute  alcohohc  delusional  insanity  which  we 
shall  study  later  on. 

Still  the  patient's  obscure  consciousness  presents 
at  times  a  temporary  lucidity.  Strong  remonstrances 
of   friends    or   grave    disorders    of   the    general   health 


370  MANUAL  OF  PSYCHIATRY. 

may  give  birth  to  repentance.  The  unhappy  subject 
regrets  his  excesses,  declares  himself  a  great  sinner, 
swears  by  all  that  is  holy  that  he  will  not  take  another 
drop  of  wine  or  licjuor,  and  announces  his  intention  to 
join  a  temperance  association.  These  good  resolutions 
are  carried  out  for  several  days,  weeks,  or  even  months; 
but  almost  always  the  patient  falls  again:  his  feeble 
will  gives  Avay  and  he  can  struggle  no  longer.  He  is 
in  a  vicious  circle:  he  drinks  because  his  will  is  weak, 
and  his  wdll  is  weak  because  he  drinks. 

When  they  attain  a  certain  degree  of  intensity,  the 
mental  disorders  which  I  have  sketched  constitute 
alcoholic  dementia. 

Alcoholic  dementia  is  slowly  progressive.  It  takes 
years  to  become  fully  established.  Moreover, — and 
this  is  a  highly  important  feature, — it  ceases  to  progress 
with  the  cessation  of  the  alcoholic  excesses. 

B.    PHYSICAL    SYMPTOMS. 

The  sleep  is  diminished,  restless,  disturbed  by  un- 
pleasant dreams.  The  patient  is  apt  to  dream  that  he 
is  at  his  occupation  (occupation-dreams);  the  work  is 
pressing,  but  in  spite  of  his  diligence  he  is  always  behind 
and  the  results  are  unsatisfactory.  At  other  thnes  ver- 
itable dramas  are  enacted:  assassins  pursue  him,  rats 
run  at  him,  snakes  and  monstrous  spiders  creep  over  him 
(zoopsia).  These  dreams  present  all  the  characteristics 
of  delirium  tremens,  which  has  been  aptly  called  a  pro- 
longed dream.  Sometimes  the  patient  wakes  up  in  the 
midst  of  his  nightmare  with  his  head  heavy,  the  body 
covered  with  perspiration,  still  doubting  the  inanity  of 
his  terrors. 


CHRONIC  ALCOHOLISM.  371 

Attacks  of  vertigo  and  flashes  of  light,  which  often 
precede  and  usher  in  apoplectiform  attacks,  occur 
in  some  cases. 

The  motor  disturbances  consist  in  muscular  weakness, 
chiefly  marked  in  the  lower  extremities,  a  tendency  to 
lassitude,  and  a  constant  tremor  affecting  especially 
the  tongue  and  the  hands ;  the  digital  tremor  is  rendered 
very  apparent  when  the  patient  holds  out  his  hand  and 
slightly  spreads  out  his  fingers:  it  is  a  fine,  vertical 
tremor,  not  very  rapid. 

The  tendon  reflexes  are  sometimes  exaggerated,  but 
much  more  frequently  diminished  or  abolished ;  the  cuta- 
neous reflexes  are  usually  exaggerated  (plantar  reflex), 
especially  in  intoxications  by  the  essences  (absinthe); 
sometimes  they  are  abolished;  the  pupils  are  paretic 
and  sometimes  slightly  myotic.  Occasionally  there  is 
a  slight  degree  of  strabismus  or  of  ptosis.  Vision 
is  frequently  impaired,  due  to  retrobulbar  neuritis; 
there  is  diminution  of  the  acuteness  and  there  may  be 
a  "central  scotoma  having  the  shape  of  an  ellipse  the 
long  axis  of  which  is  horizontal "  (Babinski) . 

Cutaneous  sensibility  is  reduced  in  the  large  majority 
of  cases;  the  hyposesthesia  is  often  unilateral;  in  such 
eases  it  is  associated  with  other  hysteroid  manifesta- 
tions: hysterogenic  zones,  globus  hystericus,  absence 
of  the  pharyngeal  reflex. 

Among  the  disorders  of  deep  sensibility  are  to  be  noted 
numbness,  tingling,  hypersesthesias  of  portions  of 
muscles  which  are  painful  on  pressure  or  are  cramped; 
dull  pains  with  lancinating  paroxysms  resembling  the 
lightning  pains  of  tabes. 


372  MANUAL   OF  PSYCHIATRY. 

The  motor  and  sensory  disturbances,  whatever 
their  distribution  may  be,  are  usually  due  to  periph- 
eral polyneuritis  which  is  a  frequent  manifestation 
of  chronic  alcoholism. 

The  gaslro-inteslinal  disorders  are  manifested  by  ano- 
rexia, pyrosis,  "  dry  retching"  in  the  morning,  slow  and 
painful  digestion,  and  constipation. 

The  liver  is  often  enlarged,  and  so  is  also  the  spleen. 
The  true  alcoholic  cirrhosis  is  sometimes  met  with,  but 
assumes  a  special  aspect,  the  principal  peculiarity  of 
which  is  absence  of  ascites. 

Diagnosis. — Chronic  alcoholism  is  to  be  differentiated 
chiefly  from  those  diseases  in  which  there  is  intellectual 
enfeeblement.  The  (juestion  of  differential  diagnosis  will 
be  considered  in  connection  with  each  of  these:  general 
paresis,  senile  dementia,  and  dementia  pnecox. 

Prognosis. — This  is  always  grave.  The  symptoms  of 
intellectual  enfeeblement  once  established  are  not  likely 
to  become  abated.  The  timely  suppression  of  alcohol 
prevents  their  appearance  or,  if  they  are  already  present, 
arrests  their  progressive  course.  Unfortunately  this  is 
very  difficult  to  accomplish. 

Pathological  anatomy. — The  arterial  system  is  tlic 
seat  of  atheromatous  degeneration  the  intensity  and 
extent  of  which  are  vai'iable;  it  affects  especially  the 
arteries  of  the  cerebrum.  Atheromatous  clianges  in  the 
arteries  at  the  base  are  frequent,  though  not  constant. 
The  arterioles  and  capillaries  may  present  a  state  of 
degeneration  characterized  by  the  presence  of  granu- 
lar masses  containing  nuclei,  which  indicate  their 
cellular  origin. 

The  nerve-ceils  undergo  "a.  certain  degree  of  gran- 


CHRONIC  ALCOHOLISM.  373 

ulo-pigmentary  and  fatty  degeneration."  ^  The  nerve- 
fibers,  especially  the  tangential  and  commissural  fibers, 
are  partially  atrophied. 

The  extent  of  the  lesions  in  the  nervous  elements  is 
proportionate  to  that  of  the  intellectual  enfeeblement. 
Therefore  it  is  especially  marked  in  cases  of  advanced 
dementia. 

The  organs  of  the  vegetative  functions  present  the 
usual  lesions  of  alcoholism:  myocarditis,  interstitial 
nephritis,  alcoholic  gastritis,  fatty  degeneration  of  the 
liver.  The  hepatic  lesions  have  become  of  special  in- 
terest since  Klippel  has  shown  that  they  are  the  imme- 
diate cause  of  certain  deliria  occurring  in  alcoholics. 

Etiology.  —  How  does  one  become  an  alcoholic? 
This  question  resolves  itself  into  two  other  questions,  as 
follows : 

1.  Why  does  a  given  individual  drink  alcohol  in 
injurious  doses? 

2.  Why  are  certain  nerv^ous  systems  more  susceptible 
than  others  to  the  poisonous  action  of  alcohol? 

.  It  would  require  a  volume  to  reply  fully  to  the  first 
question;  indeed,  it  would  mean  a  solution  of  the 
gigantic  problem  of  alcoholism  in  its  social  relations. 
According  to  Kraepelin,  heredity  seems  to  play  a  cer- 
tain role.  The  tendency  to  alcoholic  excesses  is  trans- 
mitted to  descendants.  Fere  also  states  that  "to  be- 
come an  alcoholic  one  must  be  alcoholizable ;  the  mere 
indulgence  in  fermented  beverages  is  not  in  itself  suffi- 
cient." This  factor  is  of  some  importance,  though 
shght   as   compared    with   that  of   the    social  factors. 

1  Klippel.     Du  delire  alcoolique.     Mercredi  medical,  Oct.,  1893. 


374  MANUAL  OF  PSYCHIATRY. 

Among  the  latter  the  most  powerful  is  undoubtedly 
the  widespread  ignorance  of  the  true  action  of  alcohol, 
as  well  as  the  false,  disastrous  notion  prevailing  among 
all  classes  of  society  that  alcohol  gives  force  and  is 
therefore  indispensable  to  the  workingman  in  the 
performance  of  hard  labor.  Though  it  is  to-day  a 
well-established  fact  in  the  medical  and  scientific  world 
that  alcoliol  produces  but  an  illusioii  of  force,  and  that 
the  sense  of  increased  energy  which  it  gives  is  but  a 
morbid  subjective  phenomenon,  this  idea  is  still  looked 
upon  by  the  pubUc  as  an  innovation  of  doubtful  cer- 
tainty, *'  an  invention  of  the  doctors." 

To  ignorance  is  joined  the  element  of  suggestion. 
There  can  be  no  doubt  that  many  individuals  begin  to 
drink  by  chance  or  by  example.  For  a  laborer  it  is 
almost  impossible  in  his  social  intercourse  to  escape 
alcoholism,  even  though  he  may  be  aware  of  its  dangers. 
His  comrades  drag  him  into  the  saloons,  which  constitute 
perpetual  temptations  on  his  way.  Refusal  to  accept 
their  invitations  exposes  him  to  their  ridicule  and  to 
their  ill-treatment,  and  condemns  him  to  the  isolation 
of  a  social  outcast;  here,  as  everywhere  else,  "to  do  as 
others  do  "  is  the  great  principle  that  governs  the  indi- 
vidual and  obliges  him  to  conduct  himself  against  his 
own  interest  and  even  against  his  own  inclinations. 

Among  the  social  factors  there  are  a  great  many 
special  factors  one  of  which  deserves  special  mention, 
namely,  grief.  Some  alcoholics  abandon  themselves 
to  drink  on  account  of  financial  ruin,  others  because 
of  domestic  unhappiness,  etc.  However,  it  is  to  be 
remembered  that  very  often  patients  claim  their 
misfortunes    to   have   been  the   cause   of  their  intem- 


CHRONIC  ALCOHOLISM.  375 

perance,  while  in  reality  they  are  the  effect.  The 
drunkard  pretends  that  he  drinks  to  find  rehef  from 
his  domestic  troubles,  while  in  fact  his  intemperance 
has  caused  them. 

We  now  have  to  answer  the  second  question:  Why 
does  alcohol  exert  a  rapid  and  intense  action  upon 
certain  nervous  systems,  while  others  resist  success- 
fully much  greater  exccy^es? — It  is  hero  that  indi- 
vidual predisposition  comes  into  play. 

Like  the  symptoms  of  acute  alcoholism,  those  of 
chronic  alcoholism  appear  chiefly  in  predisposed  individ- 
uals; and  the  greater  the  predisposition  the  more 
rapidly  do  these  symptoms  develop.  We  see  daily 
in-  general  hospitals  patients  presenting  atheroma  of 
the  arterial  system,  alcoholic  cirrhosis,  etc.,  and  show- 
ing but  slight  if  any  nervous  or  mental  disorders ;  while 
in  insane  asylums  patients  are  admitted  whose  alcoholic 
excesses  have  been  relatively  slight  and  whose  nervous 
systems  have  nevertheless  already  suffered  irreparable 
damage.  The  quality  of  the  soil  is  therefore  of  pri- 
mary importance. 

The  pathogenic  action  of  alcohol  is  also  favored  by 
all  the  factors  which  diminish  the  resistance  of  the 
organism,  such  as  stress,  grief,  want  of  sleep,  and  acute 
or  chronic  infectious  diseases  (tuberculosis).  Thus 
we  often  encounter,  associated  in  the  same  subject, 
the  abuse  of  alcohol,  predisposition,  and  debilitating 
influences. 

It  would  be  useful  to  know  which  among  the  alcoholic 
beverages  produce  so  great  a  toxic  action  as  to  be 
particularly  responsible  for  the  production  of  alcoholism. 
Clinical   evidence   seems    to    show    that    the   principal 


376  MANUAL  OF   PSYCHIATRY. 

factor  in  alcoholism  is  the  quantity  and  not  the  quality 
of  the  beverage  ingested.  The  experiments  of  Joffroy 
and  Serveaux  have  shown  clearly  that  alcoholic  in- 
toxication is  due  to  ethyl  alcohol  itself,  ^nd  not  to  the 
impurities  often  associated  with  it.  /Therefore  all 
fermented  beverages  may  cause  alcoholism:  liquors, 
alcoholic  tonics,  wines,  beers,  ciders,  the  alcohol  of 
beverages  as  well  as  that  of  substances  used  in  tTie 
industries.  However,  /'a  given  quantity  of  alcohol 
is  more  toxic  the  more  concentrated  it  is;  for  this 
reason  the  stronger  alcohohc  beverages  play  a  promi- 
nent role  in  the  production  of  alcoholism."^ 

Treatment.  —  xVlcoholism,  once  established,  re- 
quires no  other  treatment  than  complete  abstinence 
from  all  alcoholic  beverages.  Generally  this  can 
only  be  enforced  in  a  hospital  for  the  insane,  or  better 
still,  in  a  special  asylum  for  inebriates.-  The  patient, 
on  being  cured  of  his  drinking  habit  and  returned  to 
normal  life,  would  do  well  to  join  a  society  for  total 
abstinence  where  he  will  find  the  support  which  his 
wavering  will  power  is  still  in  need  of. 


'  Aiithcaumo.  Dc  la  toricite  d's  alcools.  These  de  Paris,  F. 
Alcan,  1S97.  I'his  work  contains  the  results  of  the  experiments  of 
JofTroy  and  Serveaux. 

^  Serieux.  Lcs  etablissoncnls  pour  le  traitement  dcs  buvcurs 
en  Angleterre  et  aux  Etatft-l'ids.  Projels  de  creation  d'asilcs  d'alcoo- 
liques  en  Autriche  el  en  France.  Bullet,  de  la  soc.  do  med.  ment.  de 
Belg.,  1895.  —  By  the  same  author.  L'assistance  des  alcooliques 
en  Suinnc  ct  en  Alleina/jne.  Ibid. — Also.  L'Asile  d^ alcooliques  de 
departemenl  de  la  Seine.     Ann.  med.  psych.,  1895,  Nov.-Dec. 


CHRONIC  ALCOHOLISM.  377 

II.   Episodic  Accidents. 

The  episodic  accidents  of  chronic  alcohoHsm  are 
of  four  kinds:  delirium  tremens,  acute  hallucinosis, 
delusional  states,  and  the  polyneuritic  psychosis. 

delirium  tremens. 

The  prodromata  consist  of  an  accentuation  of  the 
symptoms  of  chronic  alcoholism.  The  sleep  is  more 
than  ever  disturbed  by  nightmares,  preceded  by  pain- 
ful hypnagogic  hallucinations,  and  reduced  in  the  last 
days  before  the  attack  to  a  vague  somnolence.  Vio- 
lent headaches  and  a  sort  of  inexplicable  uneasiness 
usher  in  a  grave  affection.  Frequently  the  patient, 
divining  the  cause  of  the  threatening  storm,  sup- 
presses the  alcohol;  in  vain,  however,  for  the  attack 
almost  always  breaks  out  in  spite  of  the  tardy 
abstinence. 

Psychic  symptoms.  —  These  have  been  admirably 
analyzed  years  ago  by  Lasegue  and  more  recently  by 
Wernicke.  Three  chief  symptoms  dominate  the 
scene:  disorder  of  consciousness,  hallucinatory  de- 
lirium, and  motor  excitement. 

The  disorder  of  consciousness  involves  exclusively 
the  notion  of  the  external  world,  i.e.,  allopsychic 
orientation,  leaving  intact  the  notion  of  personality, 
i.e.,  autopsychic  orientation  (Wernicke). 

Illusions  and  hallucinations  are  constant  and  at 
times  incessant.  They  present  two  general  character- 
istics: (1)  they  are  painfid;  (2)  they  are  combined  in 
such  a  manner  as  to  form  complete  scenes  and  create 
around  the  patient  a  whole  imaginary  and  often  fan- 
tastic world.     They  affect  all  the  senses,  but  the 


378  MANUAL  OF  PSYCHIATRY. 

most  interesting  among  them  are  those  of  vision  and 
of  general  sensibility. 

The  visions  of  deUrium  tremens  are  always  mobile 
and  animated.  They  form  an  uninterrupted  succes- 
sion of  strange,  painful,  or  terrifying  scenes.  At  the 
same  time  that  the  patient  has  visions  of  assassins  or 
of  ferocious  and  horrible  animals,  he  feels  their  blows, 
their  bites,  or  their  repulsive  contact:  the  murderer's 
dagger  or  the  fangs  of  dogs  or  of  tigers  sink  into  his 
flesh,  spiders  run  over  his  face,  and  snakes  slip  and 
crawl  under  his  clothes. 

Two  principal  fomis  of  the  delirium  may  be  distin- 
guished :  (a)  occupation  delirium,  and  (b)  persecutory 
delirium. 

(a)  Occupation  delirium.  —  The  patient  imagines 
that  he  is  amongst  familiar  surroundings  and  at  his 
usual  occupation.  The  hallucinations  possess  re- 
markable distinctness  and  intensity:  the  cab  driver 
leads  his  horses,  urges  them  on,  whips  them,  and  runs 
over  pedestrians  who  do  not  get  out  of  his  way 
quickly;  the  caf^  waiter  waits  upon  his  clients,  re- 
ceives the  money,  and  shows  them  to  vacant  seats. 
Like  the  dreams  of  the  alcoholic  this  occupation 
delu'ium  is  always  of  a  painful  character. 

(b)  Persecutory  delirium.  —  The  psycho-sensory 
disorders  assume  a  terrifying  character.  Grimacing 
and  horrible  forms  are  seen  in  the  folds  of  the  cur- 
tains, upon  the  window-panes,  or  upon  the  walls. 
Assassins  come  out  of  every  corner;  the  ]^atient  hears 
dearly  their  threats  and  abuses  and  describes  their 
costumes  and  their  weapons.  He  sees  frightful  and 
fantastic  animals ;  rats,  snakes,  gigantic  tigers  fill  the 


CHRONIC  ALCOHOLISM.  379 

room,  constantly  changing  their  shapes  and  throw- 
ing themselves  upon  the  wretched  subject,  who  repels 
them  with  desperate  efforts.  An  odor  of  poison  pro- 
ceeds from  all  sides;  the  food  has  a  putrid  taste. 

The  motor  activity  is  at  times  very  violent.  The 
patient  walks  to  and  fro  in  the  dormitory  or  in  his 
room,  seeks  his  clothes,  strikes  the  walls  to  open  a 
passageway  for  his  escape,  emits  cries  of  terror;  or  he 
whistles  and  sings,  assuming  in  the  iritervals  a  conver- 
sational tone,  as  he  imagines  himself  surrounded  by 
his  acquaintances.  The  movements,  though  sudden 
and  awkward,  always  have  a  psychic  origin  (Wer- 
nicke); it  is  true  that  they  are  determined  by  im- 
aginary representations  and  sensations,  but  they 
invariably  present  the  character  of  purposeful  acts. 
The  patient  who  believes  himself  to  be  in  his  work- 
shop goes  through  the  regular  movements  necessary 
for  the  performance  of  his  habitual  work;  another, 
the  victim  of  terrifying  hallucinations,  executes  the 
movements  of  flight  or  of  defense. 

On  viewing  broadly  all  the  preceding  symptoms  we 
observe  that  the  hallucinations  of  delirium  tremens 
are  like  a  dream  in  action.  Just  as  a  sleeper  can  be 
awakened,  so  can  the  patient  be  momentarily  roused 
from  his  delirium  by  a  sudden  interpellation.  One 
then  obtains  correct  responses,  so  that  the  patient 
may  create  the  impression  of  a  normal  individual. 
But  as  soon  as  he  is  left  alone  he  relapses  into  his 
delirium  and  agitation. 

Physical  symptoms.  —  The  tremor  of  chronic  alco- 
hohsm  becomes  exaggerated  so  that  there  is  a  shaking 
of  the  entire  body. 


380  MANUAL  OF  PSYCHIATRY. 

The  speech^presents  a  characteristic  tremulousness. 

At  times  a  slight  degree  of  syllabic  stuttering,  para- 
phasia, facial  paresis,  or  even  hemiparesis  appears, 
showing  the  participation  of  the  projection  centers  in 
the  morbid  process. 

The  tendon  and  cutaneous  reflexes  are  usually  exag- 
gerated. 

A  certain  degree  of  hypercesthesia  is  the  rule.  The 
morbid  irritability  of  the  psycho-sensory  centers 
explains  the  facility  with  which  it  is  possible,  by  a 
simple  suggestion  or  by  slight  mechanical  stimula- 
tion, to  bring  forth  a  hallucination,  even  after  the 
spontaneous  psycho-sensory  disorders  have  disap- 
peared (induced  hallucinations  of  Liepmann).^ 

We  encounter  also  paraesthesias  and  even  anaes- 
thesias. 

Fever  is  almost  a  constant  symptom;  its  presence 
furnishes  an  excellent  element  for  prognosis  even 
regardless  of  all  complications.  In  favorable  cases 
the  temperature  does  not  rise  beyond  39°  C,  reach- 
ing its  maximum  towards  the  end  of  the  second  day. 
Defervescence  takes  place  either  rapidly  or  by  lysis. 
In  grave  cases  the  temperature  rises  above  39°  or 
even  40°  C. 

There  are  also  to  be  noted  a  dyspeptic  condition  of 
the  digestive  tract  which  is  often  very  marked;  usu- 
ally slight,  sometimes  severe  albuminuria;  a  rapid, 
full,  and  bounding  jndse  which,  in  grave  forms,  be- 
comes small  and  easily  compressible.  Under  these 
unfavorable    circumstances    the    general    nutrition 

*  Arch.  f.  I'sijchiatric,  XXVI. 


CHRONIC  ALCOHOLISM.  381 

suffers  and  there  is  loss  of  flesh  which  becomes  very 
considerable  in  a  few  days. 

Complications.  —  Among  those  involving  the  nerv- 
ous system  the  most  frequent  are  epileptiform 
seizures  which  may  precede  by  thirty-six  or  forty- 
eight  hours  the  onset  of  the  delirium,  or  they  may 
occur  during  the  attack.  The  most  formidable  as 
well  as  the  most  common  complication  is  pneumonia, 
which  affects  chiefly  the  apex  of  one  or  the  other  lung 
and  assumes  from  the  beginning  a  grave  aspect. 

Prognosis.  —  There  are  two  possible  terminations: 
recovery  and  death. 

Recovery  is  the  rule.  It  takes  place  within  four 
or  five  days  after  a  deep  and  prolonged  sleep.  The 
sleep  may  come  on  suddenly  or  it  may  be  preceded  by 
a  period  of  calmness. 

The  duration  of  delirium  tremens  is  sometimes 
abnormally  brief  (several  hours),  and  at  other  times 
abnormally  long  (a  few  weeks  or  even  months). 

Convalescence  is  marked  at  the  beginning  by  a 
certain  amount  of  confusion  which  persists  for  some 
time  and  which  may  or  may  not  be  associated  with 
delusions. 

Death  may  occur  from  exhaustion,  from  an  epilep- 
tiform attack,  or  from  some  complication  (pneu- 
monia) . 

Diagnosis.  —  Attacks  very  similar  to  delirium 
tremens  are  seen  outside  of  alcoholism,  notably  in 
senile  dementia,  in  general  paresis,  and  in  meningitis 
at  the  cerebral  convexity.  In  the  latter  affection  the 
diagnosis  is  based  upon  the  existence  of  specially 
marked  and  numerous  focal  sjTnptoms  such  as  Jack- 


382  MANUAL  OF   PSYCHIATRY. 

sonian  epilepsy,  strabismus,  etc.,  upon  the  condition 
of  the  optic  disc,  and  upon  the  course  of  the  disease. 

The  points  of  differentiation  from  general  paresis 
and  from  senile  dementia  will  be  studied  in  connec- 
tion with  these  affections. 

Pathological  anatomy.  —  To  the  lesions  of  chronic 
alcoholism  already  considered  are  added  exudative 
hypercemia  and  inflammatory  diapedesis,  which  are 
the  expression  of  an  acute  process  analogous  to  that 
observed  in  infections. 

The  nerve-cells  lose  their  normal  shape  and  struc- 
ture, their  angles  become  blunted,  and  their  chro- 
matophyUc  granulations  are  broken  up  or  disappear 
entirely.     The  nerve  fibers  degenerate. 

These  lesions  are  present  throughout  the  entire 
cortex,  including  the  centers  of  projection.  It  is  not 
rare  to  find  also  a  certain  degree  of  degeneration  in 
the  pjTamidal  bundles  and  in  the  posterior  columns. 

The  visceral  lesions  are  often  dependent  upon  some 
mfection  which  may  be  associated  with  the  alcohohc 
intoxication,  such  as  influenza,  infection  by  the  pneu- 
mococcus,  or  typhoid  fever. 

The  heart  is  the  seat  of  a  myocarditis  which  in 
many  of  the  fatal  cases  constitutes  the  immediate 
cause  of  death. 

The  liver  j:) resents  degeneration  that  is  so  fre- 
quently met  with  and  at  times  so  pronounced  that 
Klijipel  ^  has  been  led  to  attribute  delirium  tremens 
to  autointoxication  of  hepatic  orighi. 

1  Klippel.  Du  delire  dcs  alcooUqucs.  Lesio7is  analomiques  et 
jmihogmie.  Mercrccli  medical,  Oct.,  1893.  —  De  Vorigine  hejxdique 
dc  certains  delires  dcs  alcooUqucs,  Ann.  med.  psych.,  Sept.-Oct., 
1894. 


CHRONIC  AI.COHOLISM.  383 

The  lesions  in  the  kidneys  are,  according  to  Herz/ 
those  of  acute  parenchymatous  nephritis.  He  states 
that  these  lesions  are  constant.  Thus  delirium 
tremens  would  seem  to  be  nothing  but  an  attack  of 
ursemia  to  which  a  special  aspect  has  been  imparted 
by  the  chronic  alcoholism. 

Pathogenesis.  —  DeHrium  tremens  is  not  to  be  con- 
sidered as  a  simple  alcohohc  intoxication,  a  sort  of 
belated  drunkenness  caused  by  an  accumulation  of 
the  poison  in  the  organism.  Its  clinical  aspect  in 
fact  differs  radically  from  acute  intoxication.  More- 
over, the  attack  of  dehrium  is  apt  to  break  out  even 
after  the  alcohohc  excesses  have  been  suspended  for 
several  days.  Finally,  the  patient  makes  a  perfect 
recovery,  even  if  alcohol  is  administered  to  him  in 
large  doses  during  the  course  of  the  delirium. 

Some  authors,  Wernicke  among  them,  attribute 
dehrium  tremens  to  sudden  withdrawal  of  the  alco- 
hol. Experience  does  not  seem  to  bear  out  this 
opinion;  we  meet  daily  with  inveterate  alcoholics  in 
whom  complete  abstinence  does  not  produce  the 
sUghtest  damage. 

An  important  fact  upon  which  Joffroy  frequently 
insisted  in  his  lectures  is  that  delirium  tremens  often 
breaks  out  at  the  occasion  of  an  accidental  infection, 
such  as  influenza,  pneumonia,  or  suppuration.  Thus 
it  seems  that  the  disease  is  caused  by  two  agencies, 
alcoholism  on  the  one  hand  and  some  accidental 
affection,  most  frequently  an  infection,  on  the  other 
hand. 

1  Abstract  in  Centralblatt  fur  Nervenheilkunde  und  Psychiatrie, 
May,  1898. 


384  MANUAL  OF  PSYCHIATRY. 

By  what  mechanism  does  their  combination  pro- 
duce this  effect?  —  Possibly  by  determining  an  auto- 
intoxication by  insufficiency  either  of  the  Uver 
(KUppel)  or  of  the  kidneys  (Herz). 

It  should  be  remembered,  however,  that  in  many 
cases  the  second  factor,  the  accidental  infection,  is  not 
found.  Perhaps,  reduced  to  some  disorder  possess- 
ing in  itself  no  apparent  gravity,  such  as  an  attack  of 
gastric  indigestion,  it  passes  unnoticed. 

Treatment.  —  Rest  in  bed  is  very  useful  and  is 
applicable  in  the  vast  majority  of  cases.  More  than 
in  any  other  psychosis,  in  this  disease  mechanical 
restraint  is  dangerous  and  must  be  prohibited. 

The  weak  heart  action  and  the  poor  condition  of 
the  liver  and  of  the  kidneys  oblige  the  physician  to 
make  but  very  little  use  of  hypnotics,  especially  in 
severe  cases.  The  most  serviceable  and  least  danger- 
ous are  chloral  and  paraldehyde,  which,  administered 
in  large  doses,  are  of  considerable  value.  They  should 
not  be  used  without  previously  excluding  the  likeli- 
hood of  collapse. 

Letulle  has  obtained  good  results  from  cold  baths. 

Alcohol  in  some  form  was  formerly  very  popular  as 
a  remedy  in  the  treatment  of  delirium  tremens.  The 
practice  of  giving  it  is,  however,  useless,  in  most 
cases.  When  the  patient's  forces  decline  rapidly 
alcohol  may  be  given  as  a  stimulant. 

Caffein  and  ether  by  subcutaneous  injection  may 
prevent  grave  cardiac  disturbances. 

The  food  should  be  substantial  and  should  be  such 
as  to  facilitate  the  elimination  of  toxines  accumulated 
in  the  organism.     A  milk  diet  admirably  fulfills  this 


CHRONIC  ALCOHOLISM.  385 

double  indication.  Sometimes  it  is  useful  to  add 
eggs,  and  in  cases  where  there  is  much  weakness  beef- 
juice  or  chopped  meat  may  also  be  given. 

ACUTE  hallucinosis;  delusional  states. 

Acute  hallucinosis  differs  from  delirium  tremens: 
(1)  in  the  predominance  of  hallucinations  of  hearing 
over  those  of  sight ;  (2)  in  the  absence  of  any  marked 
disorder  of  consciousness;  and  (3)  in  its  course, 
which  is  of  longer  duration. 

After  a  rather  prolonged  prodromal  period  marked, 
as  in  the  case  of  delirium  tremens,  by  an  accentuation 
of  the  symptoms  of  chronic  alcoholism,  the  patient 
becomes  uneasy,  distrustful,  and  suspicious.  Gradu- 
ally false  interpretations,  illusions,  and  persecutory 
ideas  become  established.  He  does  not  dare  to  leave 
the  house,  feeling  that  he  is  being  watched,  insulted 
or  threatened  by  passers-by  or  followed  by  the  police. 
After  several  days  or  several  weeks  at  most  hallucina- 
tions of  hearing  appear  followed  often  by  hallucina- 
tions of  other  senses. 

The  disease  very  rapidly  reaches  its  height  of  de- 
velopment and  then  presents  the  following  funda- 
mental features : 

(a)  Conservation  of  lucidity:  the  patient  remains 
well  oriented,  understands  questions,  and  answers 
relevantly. 

,  (6)  Painful  character  of  the  delusions  and  of  the 
psycho-sensory  disorders:  ideas  of  persecution  of  a  va- 
riable nature :  fear  of  being  poisoned  or  assassinated, 
ideas  of  jealousy;  imaginary  insults  or  threats;  fright- 
ful visions,  especially  marked  at  night,   grimacing 


386  MANUAL  OF  PSYCHIATRY. 

figures,  ghosts,  detectives  coming  to  take  the  patient 
into  custody,  executioners,  etc.;  a  taste  or  an  odor  of 
poison  or  of  faecal  matter;  sensations  of  scalding, 
pricking,  or  electric  currents;  motor  hallucinations. 
These  latter  phenomena,  but  slightly  marked  in  the 
majority  of  cases,  point  to  a  grave  prognosis  when 
they  assume  a  certain  intensity;  they  often  forebode 
a  very  prolonged  course  of  the  disease  and  indicate 
the  existence  of  a  tendency  towards  intellectual  en- 
feeblement.  Hallucinations  of  taste  and  smell  often 
cause  refusal  of  food. 

(c)  Tendency  to  systematization:  the  patient  seeks 
an  explanation  and  a  cause  for  the  persecutions  of 
which  he  is  the  subject.  However,  the  systematiza- 
tion is  of  rapid  development  and  is  not  always  very 
accurate. 

(d)  Depressed  mood  and  aggressive  tendencies:  the 
patient,  profoundly  irritated,  wreaks  his  vengeance 
upon  innocent  victims,  being  determined  to  defend 
himself  against  the  persecutions  of  his  enemies  or 
to  escape  them  by  any  possible  means.  If  such  a 
patient  desires  to  die  it  is  not,  as  is  the  case  with 
other  classes  of  patients,  for  the  purpose  of  expiating 
some  crime  or  of  finding  relief  from  remorse,  but 
solely  to  escape  the  frightful  tortiu-es  prepared  for 
him  by  his  enemies.  Often  he  transforms  his  house 
into  a  veritable  arsenal  and,  unfortunately,  does  not 
limit  himself  to  mere  demonstrations,  but  makes 
actual  use  of  his  weapons. 

Tli(^  somatic  disorders  of  chronic  alcoholism  are  all 
])resent  in  this  affection.  Sleep  is  diminished  and 
filled  with  the  pathognomonic  dreams. 


CHRONIC  ALCOHOLISM.  387 

The  urine  often  contains  a  trace  of  albumen. 

As  a  general  rule  an  attack  of  acute  hallucinosis 
tends  towards  recovery.  This  takes  place  gradually 
after  several  weeks  or  at  most  several  months. 

The  prognosis  is,  however,  not  altogether  favorable, 
firstly  because  recurrencies  are  common,  and  secondly 
because  each  successive  attack  leaves  a  noticeable 
trace  upon  the  intelligence  and  accelerates  the  course 
of  alcoholic  dementia. 

It  is  of  great  importance  to  make  the  differential 
diagnosis  between  acute  hallucinosis  and  the  other 
affections  in  which  systematized  delusions  are  en- 
countered, viz.,  dementia  praecox,  delire  chronique, 
and  paranoia.  The  reader  is  referred  to  the  respec- 
tive chapters  devoted  to  these  diseases  for  the  points 
of  differentiation. 

The  treatment  is  that  of  chronic  alcoholism.  The 
violent  reactions  of  the  patient  usually  necessitate 
commitment.  Attacks  of  excitement  are  to  be 
treated  by  the  usual  methods. 

Betw^een  acute  hallucinosis  and  the  alcoholic  de- 
lusional states  there  is  no  sharp  line  of  demarcation; 
the  principal  distinction  is  in  the  predominance  in 
the  latter  states  of  delusions  while  hallucinations  are 
either  absent  or  play  but  a  subordinate  part.  Some 
cases  are  acute,  of  brief  duration,  and  more  or  less 
closely  connected  with  sprees  or  unusual  excesses  in 
drinking;  others  are  chronic,  subsiding  only  in  part, 
if  at  all,  upon  the  withdrawal  of  alcohol  and  lighting 
up  again  promptly  upon  the  resumption  of  drinking 
or  even  without  it  merely  upon  the  patient's  return 
from  the  institution  to  his  home  and  old  surround- 


388  MANUAL  OF  PSYCHIATRY. 

ings.  The  delusions  are  mostly  of  persecution  and 
often  may  be  plainly  seen  to  originate  from  a  sub- 
conscious effort  on  the  part  of  the  patient  to  place 
upon  others  the  blame  for  the  conditions  resulting 
from  his  intemperance:  the  fellow  workmen  annoy 
him  in  various  ways,  have  plotted  against  him,  have 
caused  him  to  lose  his  position;  his  employer  dis- 
criminates against  him;  the  labor  unions  are  spread- 
ing bad  reports  about  him  to  prevent  him  from 
getting  employment;  especially  characteristic  are 
delusions  of  jealousy  based,  for  the  most  part,  on 
misinterpretations  of  most  trivial  occurrences:  the 
bedspread  is  wrinkled  as  though  somebody  has  lain 
on  it,  the  wife  leaves  the  house  too  often  claiming  to 
go  to  the  store  or  to  visit  her  mother,  the  milkman's 
"Good  morning"  seems  suspiciously  friendly,  the 
coffee  tastes  queer,  probably  on  account  of  poison 
put  in  by  the  wife  to  get  rid  of  the  patient.  These 
delusions  often  lead  to  violent  quarrels,  disgraceful 
scenes,  beating,  and  threats  or  even  attempts  of 
homicide. 

THE    POLYNEURITIC    PSYCHOSIS. 

The  polyneuritic  psychosis  or  Korsakoff's  disease  ^ 
is  an  affection  characterized  by  the  association  of  the 
phenomena  of  polyneuritis  with  specific  mental  dis- 
turbances among  which  amnesia  of  diverse  forms  con- 
stitutes a  preponderant  feature.  Although  it  occurs 
most  frequently  on  a  basis  of  chronic  alcoholism,  it 

'  Congres  de  Medecine,  1889.  —  Luckerath.  Bcilrag  zu  der 
Lehre  von  der  Korsakow' schen  Psychose.  Neurol.  Centralblatt, 
April,  1900. 


CHRONIC  ALCOHOLISM.  389 

is  also  sometimes  observed  independently  of  chronic 
alcoholism,  following  a  profuse  hemorrhage  or  an 
infectious  disease,  such  as  influenza. 

Symptoms.  —  In  some  cases  the  symptoms  of  the 
polyneuritic  psychosis  appear  gradually,  without  any 
striking  phenomena  at  the  onset;  much  more  often 
the  onset  is  acute:  agitation,  numerous  hallucina- 
tions, and  anxiety  render  the  resemblance  to  delirium 
tremens  so  marked  as  to  lead  very  frequently  to  errors 
in  diagnosis.  After  several  days  the  agitation  sub- 
sides, but  the  disorientation  persists  and  the  char- 
acteristic amnesia  appears  together  with  the  phe- 
nomena of  polyneuritis. 

The  amnesia  is  both  anterograde  and  retrograde. 

The  anterograde  amnesia  results  from  the  total  abo- 
lition, or  at  least  a  marked  diminution,  of  the  power 
of  fixation.  The  patient  forgets  in  a  few  moments  a 
visit  which  he  has  received  or  the  gist  of  what  he  has 
just  read.  On  leaving  the  table  he  asks  whether  it  is 
not  almost  time  for  dinner  and  complains  of  having 
no  appetite. 

The  retrograde  amnesia  is  purely  functional,  by  de- 
fault of  reproduction;  on  recovery  from  the  disease 
the  old  representations  reappear  intact. 

The  effacement  of  representations  occurs  in  con- 
formity to  the  law  of  retrogression.  Depending  upon 
the  severity  of  a  particular  case,  the  amnesia  involves 
the  events  of  a  more  or  less  considerable  period  of 
time. 

Pseudo-reminiscences,  illusions,  and  hallucinations 
of  memory  fill  the  gaps  created  by  the  amnesia.  Thus 
quite  frequently  the  patient  is  totally  unconscious  of 


390  MANUAL  OF  PSYCHIATRY. 

his  disorder  of  memory  and  unhesitatingly  repUes  to 
all  questions  put  to  him.  Often  also,  modifying  facts 
of  which  his  impression  is  more  or  less  vague,  adjust- 
ing some  details  and  suppressing  others,  the  patient 
narrates  imaginary  occurrences  the  principal  features 
of  which  are  their  mobility,  their  easy  modifiahility 
by  api)roi)riate  suggestions,  and  their  being  usually 
limited  to  the  bounds  of  possibility.  The  latter 
characteristic  is,  however,  not  constant,  for  the  fabri- 
cations in  the  polyneuritic  psychosis  may  be  alto- 
gether improbable  or  even  absurd. 

The  following  specimen  has  been  taken  from  an 
observation  made  upon  a  case  of  polyneuritic  psy- 
chosis due  to  absinthe: 

Q.  How  long  have  you  been  here? 

A.  Since  this  morning. 

Q.  What  were  you  doing  yesterday? 

A.  I  went  to  the  market  to  buy  some  eggs.  After 
that  I  went  to  see  my  sister  and  took  dinner  with  her. 

Q.  Don't  you  ever  go  the  theatre? 

A.  Oh,  that's  true,  ...  I  went  there  after  work  last 
night  ...  it  was  very  beautiful. 

Q.  WTiat  play  did  you  see? 

A.  Really  .  .  .  just  wait  a  minute  ...  it  was  very 
beautiful  .  .  .  they  sang  .  .  .  they  had  superb  cos- 
tumes ...  I  cannot  recollect  the  name  of  the  play. 

In  reality  the  patient,  who  had  been  in  the  asylum 
during  the  three  weeks  previous,  had  not  left  his  bed 
since  his  admission  on  account  of  a  very  marked 
paresis  of  both  lower  extremities. 

To  these  pathognomonic  disturbances  of  memory 
are  added  also  complete  loss  of  orientation  of  time  and 


CHRONIC  ALCOHOLISM.  391 

place,  numerous  illusions  which  often  lead  to  mis- 
takes of  identity,  and  occasional  hallucinations  which 
are  more  or  less  fleeting. 

The  emotional  tone  is  usually  one  of  indifference; 
sometimes  there  is  slight  euphoria  or  undue  irrita- 
bihty. 

In  spite  of  their  intensity  the  psychic  symptoms 
are  in  many  cases  not  very  apparent  at  first.  The 
patients  are  quiet,  understand  well  the  questions  put 
to  them,  and  reply  in  a  calm  and  often  even  in  an  in- 
telligent manner.  They  often  appear  to  be  normal 
because  a  conversation  of  several  minutes  may  not 
suffice  to  reveal  the  pathognomonic  amnesia  and 
disorientation. 

The  signs  of  polyneuritis,  paresis  of  the  lower  ex- 
tremities, abolition  of  the  tendon  reflexes,  parsesthe- 
sias,  lightning  pains,  hypersesthesias  of  circumscribed 
muscular  masses,  —  to  mention  only  the  principal 
ones,  —  vary  widely  in  intensity.  They  are  at  times 
mild,  while  the  mental  disturbance  may  be  quite 
marked.  Possibly  they  may  be  even  entirely  want- 
ing in  certain  cases  that  are  perfectly  typical  from 
the  psychic  standpoint. 

The  general  health  is  always  affected  to  some  extent. 
Occasionally  cachexia  may  develop  and  end  fatally. 
Also  cardiac  -disturbances  are  often  noted,  feeble 
action,  irregularity,  etc.,  which  in  a  number  of  cases 
are  dependent  upon  a  neuritis  of  the  pneumogastric 
nerve. 

Duration,  prognosis,  diagnosis.  —  The  duration  of 
the  active  period  of  the  disease  is  usually  several 
months,  seldom  over  a  year.     There  then  remains  a 


392  MANUAL  OF  PSYCHIATRY. 

characteristic  state  of  mental  deterioration  dependent 
upon  a  persisting  and  more  or  less  pronounced  im- 
pairaient  of  the  power  of  retention,  with  resulting 
disorientation  and  amnesia  for  recent  occurrences. 
The  tendency  toward  active  fabrications  and  pseudo- 
reminiscences  becomes  less  marked  and  often  dis- 
appears. 

In  some  few  cases  there  is  partial  restoration,  so 
that  the  patients  are  again  able  to  keep  track  of  dates 
and  current  events,  but  complete  recovery  is  a  rare 
exception  in  alcoholic  cases,  though  it  is  said  to  be 
common  in  cases  with  a  different  etiology. 

Another  mode  of  termination,  also  infrequent,  is 
death,  which  results  either  from  cachexia  or  from 
some  intercurrent  complication:  influenza,  pneu- 
monia, tuberculosis. 

The  diagnosis  is  based  on  (a)  the  very  marked  and 
characteristic  disorders  of  memory;  (6)  the  apparent 
lucidity  of  the  patient,  contrasting  with  the  real  dis- 
orientation;  (c)  the  coexisting  signs  of  polyneuritis. 

Treatment.  • — •  The  treatment  in  the  acute  stage 
of  the  disease  consists  chiefly  of  rest  in  bed  combined 
with  a  reconstructive  diet. 

It  is  scarcely  necessary  to  add  that  abstinence  from 
all  alcoholic  beverages  should  be  rigorously  enforced, 
especially  where  alcohohsm  is  the  cause. 


CHAPTER  XI. 

GENERAL  PARESIS. 

Synonyms.  —  Chronic  arachnitis  and  chronic  meningitis  (Bayle). 
Incomplete  general  paralysis  (Dclaye).  General  paralysis  of  the 
insane  or  chronic  diffuse  periencephalo-meningitis  (Calmiel).  Para- 
lytic infinity  (Parchappe).  Progressive  general  paralysis  (Lunier, 
Sadras).  Paralytic  dementia  (Baillarger) .  Chronic  diffuse  inter- 
stitial encephalitis  (Magnan).  In  German:  Progressive  allgemeine 
Paralyse.  In  general  it  is  convenient  to  employ  the  Latin  term 
dementia  paralytica. 

The  earliest  mention  of  the  somatic  and  psychic 
disorders  corresponding  to  general  paresis  dates  back 
to  1798,  when  Haslam,  pharmacist  at  the  Bethlehem 
Hospital,  described  in  a  few  lines  and  with  remark- 
able precision  the  principal  features  of  the  disease. 

It  was  only  in  1822,  thanks  to  the  memorable  work 
of  Bayle,  that  general  paresis  gained  a  footing  in 
classical  psychiatry.  The  history  of  this  disease  is  a 
subject  much  too  vast  for  the  limits  of  this  work.  It 
has  been  quite  recently  treated  by  Vignaud  ^  in  his 
inaugural  thesis,  which  contains  also  a  good  bibliog- 
raphy.2 

1  Histoire  dc  la  paralysic  generale.     Paris.     These. 

-  Monographs  on  general  paresis:  Lasegue.  De  la  paralysic 
gmerale  progressive.  Th.  d'agreg.  Paris,  1853;  also  Lecons  sur 
hi  paralysic  generale,  1883.  —  Falrct.  Recherches  sur  la  folic  paralyt- 
iqiic  et  les  diverses  paralysies.  Paris,  1853.  —  Voisin.  Traite  de 
la  paralysic  generale.  1879.  —  Baillarger.  Theorie  de  la  paralysic 
gin&rale.     Ann.    med.    psych.,     1883.  —  iSIendel.     EHe    progressive 

393 


394  MANUAL  OF  PSYCHIATRY. 

F*rodromal  period.  —  It  is  marked  (a)  by  changes 
of  affectivity  and  of  the  character;  (b)  by  neuras- 
thenic and  psychasthenic  phenomena. 

(a)  The  mood  becomes  either  irritable  and  change- 
able, with  sudden  alternations  of  joy  and  sorrow, 
kindness  and  anger,  discouragement  and  optimism; 
or  gloomy,  and  marked  by  pessimism  and  by  a 
tcedium  vitce  which  may  lead  the  patient  to  attempts 
of  suicide.  Often  the  patient  is  conscious  of  being 
stricken  with  a  grave  disease  and  has  dark  presenti- 
ments for  the  future. 

(6)  The  neurasthenic  and  psychasthenic  symptoms 
are  usually  very  pronounced:  a  feeling  of  general 
lassitude,  fatigue,  muscular  weakness,  diffuse  neural- 
gic pains,  headache,  a  sort  of  grinding  sensation  felt 
especially  in  the  head,  and  other  peculiar  sensations 
which  the  patient  is  unable  to  describe  clearly:  it  may 
seem  to  him  that  his  head  is  empty,  that  his  brain  is 
falling  to  pieces,  etc. 

These  symptoms  are,  however,  not  identical  with 
those  of  true  neurasthenia.  The  following  are,  ac- 
cording to  Ballet,  the  most  important  points  of  dif- 
ference : 


nllgnncine  Paralyse  der  Irrcn,  1880.  —  Mairet  ct  ViroH.  De  la 
parol yftic  qenerale.  Etiolofj;ie.  Pathogenie.  TraitPinent.  1893. — 
Magnan  ot  Serioux.  La  paralysie  qeneralc  (colloction  L^auto), 
1 894.  —  Couloii.  Conndcralions  hut  la  nature  de  la  paralysie  genSrale. 
—  Klippel.  Jjen  paralysics  (jencrales.  L'ocuvrc  mcdico-chirurgicale, 
1898.  —  For  a  lMl)lingi-ai)hy  of  general  paresis,  sec  G.  Ballet  et 
J.  Rogues  de  Fursac.  Article  Paralysie  (lenerale  in  Trait6  de 
M^decine  Charcot-Bouchard-Brissaud.  Paris,  1905.  —  E.  Krae- 
peiin.  General  Paresis.  Eng.  trans.  l)y  J.  Moore.  Nerv.  and  Ment. 
Dis.  Monograph  Series.     New  York,  1914. 


GENERAL  PARESIS.  395 

"(1)  The  stigmata,  that  is  to  say,  the  permanent 
signs  of  neurasthenia  (helmet  sensation,  pain  in  the 
spine),  are  usually  absent. 

"(2)  Neuralgic  pains  occupy  a  prominent  place  in 
the  chnical  picture.  These  pains  (excluding  the 
hghtning  or  lancinating  pains  dependent  upon  the 
spinal  lesions  of  general  paresis)  are  disseminated, 
essentially  mobile,  varying  from  day  to  day.  The 
patients  often  speak  of  them  as  'pains  that  are  pecu- 
liar, unusual.^ 

"  (3)  From  one  moment  to  another  sudden  changes 
are  produced  in  the  state  of  the  patient.  .  .  .  It  is 
surprising  to  see  the  neurasthenic  paretic,  who  but  a 
short  time  before  complained  of  severe  suffering  and 
ill  health,  forget  his  pains  under  the  influence  of  some 
incident  or  conversation  in  which  he  is  interested  and 
in  which  he  takes  an  active  part.  These  momentary 
changes,  appearing  at  the  instance  of  chance  occur- 
rences, may  manifest  themselves  in  a  more  lasting 
manner  on  instituting  some  treatment,  though  in- 
significant. The  patient,  hitherto  excessively  dis- 
couraged and  gloomy,  speaks  with  joy  of  his  cure; 
his  satisfaction  is  exuberant  and  out  of  proportion, 
as  was  his  despair  shortly  before." 

Often  some  transient  phenomenon,  exceptional  or 
unknown  in  neurasthenia,  alarms  the  physician: 
slight  seizures,  transitory  strabismus  with  diplopia, 
slightly  marked  momentary  disorders  of  speech. 

The  period  of  prodromata  is  seldom  absent.  It 
is  often  very  long,  lasting  several  months  or  even 
years. 


396  MANUAL  OF   PSYCHIATRY. 

§1.   Essential  Symptoms. 

It  will  be  necessary  to  consider  these  apart  from 
accessory  and  inconstant  symptoms,  by  the  presence 
of  which  they  are  often  masked. 

The  essential  symptoms  are: 

(A)  Intellectual  enfeeblement; 

(B)  Disorders  of  motility; 

(C)  Pupillary  disturbances; 

(D)  Changes  in  general  nutrition. 

(A)  Intellectual  enfeeblement.  —  It  presents  two 
fundamental  characteristics : 

(1)  It  affects  all  the  psychic  functions  in  their 
ensemble; 

(2)  It  is  progressive,  and  usually  rapidly  so.  This 
latter  characteristic  distinguishes  paralytic  dementia 
from  senile  dementia,  the  development  of  which  is 
much  slower. 

Let  us  analyze  rapidly  the  elements  constituting 
this  intellectual  enfeeblement. 

(a)  Memory.  —  It  is  profoundly  affected  from  the 
very  beginning.  The  amnesia  is  both  anterograde,  by 
default  of  fixation,  and  retrograde,  by  destruction  of 
impressions.     It  is  essentially  incurable. 

The  disappearance  of  old  impressions  probably  fol- 
lows the  law  of  amnesia;  but  its  course  is  so  rapid  that 
it  is  difficult  to  demonstrate  this  fact.  The  impres- 
sions of  youth  and  childhood  become  very  rapidly 
effaced,  so  that  after  a  relatively  short  period  only  a 
few  confused  and  distorted  recollections  remain  in 
the  mind  of  the  patient,  and  these  are  only  with  great 
difficulty  recovered  from  the  general  wreck. 


GENERAL  PARESIS.  397 

(6)  Consciousness  and  perception.  —  Their  dis- 
orders are  manifested  by: 

(I)  A  more  or  less  complete  loss  of  orientation  in  all 
its  forms; 

(II)  A  more  or  less  confused  perception  of  the  ex- 
ternal world. 

The  clouding  of  consciousness  and  the  confusion 
attain  in  the  terminal  period,  and  in  certain  forms  in 
the  beginning,  an  extreme  intensity. 

(c)  Attention  and  association  of  ideas.  —  The  atten- 
tion of  the  patient  is  difficult  to  rouse  as  well  as  to  fix. 
In  some  cases,  early  in  the  disease  in  phases  of  excite- 
ment, exaggeration  of  the  mental  automatism  gives 
rise  to  true  flight  of  ideas.  This,  however,  is  of  ex- 
ceptional occurrence;  as  a  rule  there  is  sluggish  for- 
mation of  associations  of  ideas  demonstrable  by 
psychometry  or  by  an  ordinary  clinical  examination. 
In  the  cases  in  which  some  mental  activity  is  still 
possible  there  is  rapid  mental  fatigability,  so  that 
the  patient  is  no  longer  able  to  do  mental  work  of  any 
complexity' ;  in  advanced  stages  even  the  simplest 
intellectual  operations  are  impossible. 

(d)  Affectivity.  —  Its  changes  are  characterized  by 
morbid  indifference  and  irritability,  associated  in  the 
manner  already  described.^  Both  the  indifference 
and  the  irritability  are  apt  to  be  very  marked.  The 
general  paretic  takes  no  interest  in  his  own  business 
affairs  or  in  the  welfare  of  his  relatives.  Grave  oc- 
currences fail  to  impress  him.  On  the  other  hand, 
he  is  subject  to  fits  of  terrible  anger  on  the  shghtest 
provocation. 

1  See  Part  I,  Chapter  IV. 


398  MANUAL  OF  PSYCHIATRY. 

The  moral  sense  and  regard  for  conventionalities 
disappear  entirely.  The  patient  commits  the  most 
ridiculous  and  most  revolting  acts  with  perfect 
serenity  and  is  astonished  when  his  liberty  of  action 
is  interfered  with. 

(e)  Judgment.  —  Its  disorder  finds  expression  in 
the  patient's  total  lack  of  insight  into  his  condition. 
Together  with  the  amnesia,  it  explains  the  inconsist- 
encies in  the  patient's  conduct  and  speech;  he  is 
unable  to  appreciate  the  most  flagrant  contradictions. 
To  a  given  question  the  paretic  gives  the  first  answer 
that  enters  his  mind,  whether  it  happens  to  be  false 
or  correct,  absurd  or  plausible. 

(/)  Reactions.  —  As  might  be  expected,  they  are 
always  impulsive.  The  reflections,  that  is  to  say  the 
series  of  associations  preceding  the  act,  become  more 
and  more  reduced.  As  the  patient  sees  what  he 
wants  he  immediately  takes  it.  He  wants  an  object 
that  he  sees  exposed  for  sale  in  a  shop  —  he  takes  it 
and  carries  it  off  without  taking  the  trouble  to  pay 
for  it.  A  paretic  leaning  over  the  parapet  of  a  bridge 
drops  his  cane.  To  recover  it,  reasoning  that  a 
straight  line  is  the  shortest  distance  between  two 
points,  he  jumps  after  it  into  the  water.  Stereo- 
typed movements  (movements  of  sucking,  grmding 
the  teeth,  etc.)  and  negativism  are  frequent.  Cata- 
leptoid  attitudes  arc  occasionally  seen. 

(B)  Motor  disturbances.  —  The  fundamental  motor 
disturbances,  the  only  ones  that  need  occupy  us 
here,  are  three  in  number: 

(a)  Progressive  muscular  weakness;  (6)  Tremors; 
(c)  Motor  incoordination. 


GENERAL  PARESIS.  399 

(a)  Muscular  weakness.  —  It  is  most  marked  in  the 
latter  periods  of  the  affection,  when  it  accompanies 
the  general  cachexia.  It  involves  all  the  muscles  and 
is  associated  with  more  or  less  pronounced  atrophy  so 
that  there  is  more  or  less  complete  disability. 

(6)  Tremors.  —  Unlike  the  muscular  weakness, 
these  constitute  an  early  symptom.  They  are  of  two 
kinds:  fibrillary  tremors  and  tremors  en  masse. 

(I)  The  fibrillary  tremors  consist  in  rapidly  re- 
peated contractions  of  very  small  groups  of  muscular 
fibers.  It  is  a  sort  of  twitching.  It  is  observed 
chiefly  in  the  tongue  and  in  the  peribuccal  muscles, 

(II)  Tremors  en  masse  usually  appear  as  coarse 
oscillations  irregular  in  frequency  and  in  amplitude. 
They  become  evident  on  voluntary  movements  and 
form  a  sort  of  point  of  transition  between  true  trem- 
ors and  muscular  ataxia.  They  are  seen  especially 
in  the  upper  extremities  and  in  the  tongue.  The 
tongue  projected  from  the  mouth  executes  to-and-fro 
movements  very  aptly  described  by  Magnan  as 
''trombone  movements." 

(c)  Motor  incoordination.  —  This  first  becomes  evi- 
dent in  the  most  delicate  movements  and  manifests 
itself  early  by  impairment  of  the  speech  and  of  the 
handwriting. 

I.  The  impairment  of  speech,  clearly  apparent  in 
advanced  stages,  is  sometimes  difficult  to  notice  at 
the  beginning  and  becomes  evident  only  on  resorting 
to  special  tests,  such  as  prolonged  reading  in  a  loud 
voice  or  the  pronunciation  of  special  words  known 
as  test- words:  Methodist  Episcopal,  fourth  cavalry 
brigade,  national  intelligence,  etc. 


400  MANUAL  OF  PSYCHIATRY. 

Sometimes  the  impairment  of  speech  becomes  less 
evident  or  even  disappears  temporarily  dming  excite- 
ment. Often  it  becomes  accentuated  after  apoplecti- 
form or  epileptiform  attacks. 

It  is  of  various  types,  the  principal  of  which  are  the 
following : 

(a)  Drawling,  tremulous,  indistinct  speech; 

(0)  Scanning  speech  analogous  to  that  of  dissemi- 
nated sclerosis; 

(7)  Hesitating  speech:  the  patient  stops  in  the 
middle  of  a  word  and  seems  to  hesitate  before  finish- 
ing it; 

(5)  Omission  of  one  or  of  several  syllables:  the 
patient  pronounces,  for  instance,  ''Methist  Pispal" 
instead  of  Methodist  Episcopal; 

(e)  Reduplication  of  one  or  of  several  syllables,  as 
"  constititutional " ; 

(f)  Interchange  of  syllables:  ''constutitional." 
These  types  may  be  combined  so  as  to  form  mixed 

types  of  infinite  varieties. 

II.  The  handwriting  is  characterized  by  its  irregu- 
lar appearance,  and  by  the  coarse  tremors  seen  in  the 
strokes.  These  motor  disorders  are  always  associ- 
ated with  phenomena  of  intellectual  origin :  omissions, 
or,  on  the  contrary,  repetitions  of  letters,  syllables,  or 
words,  numerous  glaring  orthographical  errors.  All 
these  features  impart  to  the  handwriting  of  paresis 
its  characteristic  aspect. 

Usually  the  patient  is  totally  unconscious  of  these 
symptoms.  If  accidentally  he  notices  them,  he  is 
neither  surprised  nor  alarmed.  The  explanations 
which  he  gives  are  childish:  he  does  not  speak  well 


GENERAL  PARESIS.  401 

because  he  has  lost  a  tooth,  or  he  writes  with  difficulty 
because  his  hands  are  cold. 

Slight  in  the  beginning,  the  impediment  of  speech 
and  the  impairment  of  handwriting  become  progres- 
sively aggravated,  so  that  in  the  terminal  stage  of  the 
disease  the  writing  becomes  shapeless  scribbling  and 
the  speech  unintelligible  stammering. 

At  the  end  of  the  disease  it  is  almost  constant  to 
note  disturbance  of  deglutition  caused  by  paresis  and 
incoordination  of  the  pharyngeal  muscles,  which  may 
entail  death  by  suffocation. 

(C)  Pupillary  disorders.^ — These  appear  some- 
times very  early. 

They  are  dependent  upon  an  internal  ophthalmo- 
plegia of  gradual  and  progressive  development  (Baillet. 
and  Bloch),  which  is  manifested  by  changes  in  the 
shape,  size,  and  reactions  of  the  pupil. 

(a)  Changes  in  the  shape.  —  The  pupil  loses  its 
circular  shape  and  becomes  oval  or  irregular.  This 
symptom  seems  to  be  frequent,  but  of  its  diagnostic 
value  little  is  known. 

(6)  Changes  in  size.  —  These  are  of  three  kinds: 

I.  Myosis,  at  times  so  marked  that  the  pupils  are 
reduced  to  pin-hole  size. 

II.  Mydriasis,  also  very  well  marked  in  certain 
cases. 

III.  Inequality,  which  may  be  produced  by  three 
different  mechanisms: 

(a)  One  pupil  is  normal,  the  other  myotic  or 
mydriatic ; 

1  Mignot.  Contribution  a  V etude  des  troubles  pupiUaires  dans  qud- 
gues  maladies  mentales.     These  de  Paris,  1900. 


402  MANUAL  OF  PSYCHIATRY. 

(/3)  One  pupil  is  mydriatic,  the  other  myotic; 

(7)  Both  pupils  are  mydriatic  or  myotic,  but  are 
unequally  dilated  or  contracted. 

It  is  important,  in  order  to  make  a  satisfactory  ex- 
amination of  the  pupils,  to  place  the  patient  in  such  a 
light  that  both  eyes  receive  an  equal  amount  of  illu- 
mination. It  is  also  important  to  vary  the  intensity 
of  illumination,  because  an  inequality  that  appears 
doubtful  in  a  strong  light  may  become  very  evident 
in  a  weaker  light,  and  vice  versa. 

Pupillary  inequality  is  sometimes  congenital. 
Moreover,  it  is  encountered  in  many  affections 
other  than  general  paresis:  dementia  prsecox,  com- 
pression of  the  sympathetic  nerve,  etc.;  therefore  it 
does  not  by  any  means  constitute  a  pathognomonic 
sign. 

(c)  Changes  in  the  reflexes.  —  These  consist  in 
changes  in  the  light  reflex,  or  in  the  accommodation 
reflex,  or  in  both.  They  are  either  binocular  or 
monocular. 

Disorders  of  the  pupillary  reactions  may  be  associ- 
ated as  in  the  Argyll-Robertson  type :  abolition  of  the 
light  reflex  with  persistence  of  the  accommodation 
reflex.  This  combination  is,  however,  considerably 
less  frequent  in  paresis  than  in  tabes. 

At  the  beginning  of  the  disease  the  reactions  are 
not  completely  abolished,  but  are  simply  paretic. 

It  is  not  uncommon  for  the  speech  defect  and  the 
pupillary  signs  to  persist  through  complete  mental 
remissions. 

( 1 ))  Changes  in  general  nutrition.  —  Though  con- 
stant and  very  important  they  have  thus  far  received 


GENERAL  PARESIS.  403 

but  little  attention.  Clinically  we  find  changes  in 
the  weight  and  in  the  urinary  secretion. 

The  onset  is  almost  always  marked  by  considerable 
loss  of  weight.  Later  the  weight  varies  with  the 
clinical  form. 

In  the  excited  and  in  the  depressed  forms  of  rapid 
evolution  the  loss  of  weight  is  marked  and  progres- 
sive, and  the  patient  rapidly  becomes  cachectic. 

In  the  expansive  or  demented  forms  the  weight 
often  rises  after  the  initial  fall,  the  patient  then  be- 
coming corpulent  and  remaining  so  until  the  terminal 
stage,  when  the  weight  may  fall  suddenly  and  con- 
tinue to  drop  as  marasmus  is  established. 

Organic  crises  may  be  noted  in  the  course  of  the 
disease  (Arnaud);  they  consist  in  a  transitory  but 
considerable  loss  of  weight,  the  cause  of  which  is 
unknown. 

The  changes  in  the  urinary  secretion  indicate 
general  sluggishness  of  nutrition.  They  have  been 
especially  studied  in  connection  with  the  second 
period  of  the  disease.  The  principal  ones  are  poly- 
uria, low  specific  gravity  of  the  urine,  slight- albumin- 
uria, very  considerable  diminution  of  urea  and  of 
phosphates,  and  increase  of  chlorides.^ 

A  study  of  the  blood  changes  might  also  be  of  great 
interest.  The  work  already  done  along  this  line  is 
unfortunately  very  scant  and  inconclusive.  Capps  ^ 
found  a  slight  diminution  of  haemoglobin  and  of  the 
red  blood  cells. 

1  Klippel  et  Serveaux.  Contribution  a  I' etude  de  V urine  dans  la 
paralysie  generate.  Congres  des  medecins  alienistes  et  neurolo 
gistes,  1895. 

2  American  Journ.  of  the  Med.  Sc,  1896,  No.  290. 


404  MANUAL  OF  PSYCHIATRY. 

§  2.   Inconstant  Symptoms. 

Many  symptoms  though  not  constant  are,  how- 
ever, frequent  and  miportant. 
This  group  comprises: 

(A)  Intellectual  disorders; 

(B)  Motor  disorders; 

(C)  Disorders  of  the  reflexes; 

(D)  Disorders  of  sensation; 

(E)  Trophic  disorders;. 

(F)  Visceral  disorders; 

(G)  Epileptiform  and  apoplectiform  seizures. 

(A)  Intellectual  disorders.  —  The  principal  are  de- 
lusions and  hallucinations. 

(a)  The  delusions  of  the  general  paretic  are  of  the 
demented  type;  that  is  to  say,  they  are  absurd,  mobile, 
multi'ple,  and  contradictory. 

They  assume  all  forms; 

(a)  Ideas  of  grandeur:  the  patient  is  immensely 
rich;  millions  are  not  adequate,  the  general  paretic 
counts  his  riches  by  trillions;  he  governs  the  forces 
of  nature,  resuscitates  the  dead,  is  the  incarnation 
of  all  the  great  men  of  the  present  and  of  the  future, 
destroj^s  and  reconstructs  the  universe  by  a  single 
gesture,  etc. 

{^)  Melancholy  ideas:  ideas  of  culpability :  one  pa- 
tient accused  himself  of  having  hastened  the  end  of 
the  world  by  ten  thousand  centuries;  hj'pochondri- 
acal  ideas:  another  patient  refused  to  eat  because  he 
had  ''a  bicycle  manufactory  in  the  throat";  ideas  of 
negation:  the  organs  are  liquefied  or  replaced  by  air, 
the  body  is  nothing  but  a  putrefied  corpse;  ideas  of 
ruin  analogous  to  those  of  melancholia. 


GENERAL  PARESIS.  405 

(7)  Persecutory  ideas:  they  are  either  primary  or 
secondary  to  ideas  of  grandeur.  In  the  latter  case 
the  patients  complain  that  they  have  been  robbed  of 
their  immense  fortune,  that  they  are  n6t  treated  with 
the  respect  to  which  they  are  entitled,  that  they  are 
unjustly  detained  in  the  asylum,  etc.  Occasionally 
at  the  beginning  persecutory  ideas  become  systema- 
tized,^ but  always  imperfectly.  A  close  examination 
always  reveals  certain  flagrant  contradictions  by 
which  the  intellectual  enfeeblement  manifests  itself. 

(6)  The  frequency  of  hallucinations  in  general 
paresis  is  a  much  disputed  question.  Some  authors 
believe  that  they  are  almost  constant  (Christian  and 
Ritti),  or  at  least  frequent  (Wernicke);  others  claim 
that  they  are  rare  (Magnan,  Dagonet,  Krafft-Ebing). 
The  latter  opinion  is  the  more  widely  accepted  one 
and  I  believe  the  more  correct  one. 

The  hallucinations  may  affect  any  of  the  senses, 
including  the  muscular  sense. 

Illusions  are  much  more  frequent  than  hallucina- 
tions. 

Psycho-sensory  disorders  are  encountered  chiefly 
in  the  excited  form  of  general  paresis,  in  which  they 
are  associated  with  incoherent  delusions. 

The  systematized  persecutory  delusions  which  are 
occasionally  met  with  are  apt  to  be  associated  with 
auditory  hallucinations. 

As  in  all  cases  of  pronounced  dementia,  the  reac- 
tions and  the  emotional  tone  do  not  always  harmonize 
with  the  delusions.     A  general  paretic  who  beUeves 

*  Magnan.     Lecons  diniques. 


406  MANUAL  OF  PSYCHIATRY. 

himself  to  be  dead  may  eat  heartily  and  remain 
otherwise  unaffected. 

The  following  case  illustrates  the  type  of  delusions 
in  general  paresis: 

Marie  B.,  thirty-two  years  old,  cafe  singer.  —  Family  history 
unknown.  —  Patient  occasionally  drinks  to  excess.  Syphilis  very 
probable,  as  patient  has  lived  for  some  years  with  a  man  who  had 
syphilis.  She  had  two  still-births.  —  She  was  arrested  for  creating 
a  disturbance  on  a  public  thoroughfare  and  was  sent  to  the  Cler- 
mont Asylum.  On  the  way  to  the  asylum  she  was  greatly  excited, 
spoke  of  her  immense  fortune,  distributing  millions  among  those 
about  her,  made  indecent  signs  to  all  the  men  she  met,  but  sub- 
mitted readily  to  being  taken  to  the  asylum. 

Two  days  after  her  arrival  at  the  asylum,  at  the  time  that  this 
record  was  made,  the  patient  showed  marked  excitement.  Her 
face  was  red,  her  eyes  sparkling.  She  was  very  voluble,  yet  quite 
tractable.  Her  orientation  was  very  imperfect,  delusions  extremely 
active.  She  said  that  she  was  in  a  town  called  Clermont,  and  that 
she  had  been  there  three  months;  that  it  was  the  spring  of  1894 
(in  reality  March,  1904);  that  the  institution  she  was  in  was  a 
hospital  for  wounded  soldiers.  It  was  pointed  out  to  her  that 
there  were  no  soldiers  there.  "That  is  true,"  she  said,  "they  are 
in  Nice.  I  take  good  care  of  them.  I  do  not  put  them  in  a  dun- 
geon, but  in  a  beautiful  room."  She  knew  at  once  that  there  were 
insane  patients  at  the  asylum,  but  there  are  no  longer  to  be  any 
there,  as  to-morrow  she  is  going  to  cure  them  all  with  a  good 
cathartic.  She  had  already  cured  her  husband  "of  a  filthy  disease 
by  cleaning  out  his  bowels."  This  husband  of  hers  married  the 
daughter  of  a  colonel  who  left  him  two  days  after  the  wedding. 
The  patient  states  that  she  herself  had  also  been  sick;  sjje  was 
operated  on  by  Duchess  de  C,  then  went  for  six  months  without 
making  water  or  moving  her  bowels,  but  she  was  never  sick  enough 
to  go  to  bed,  neither  were  her  horses.  She  has  ten  thousand  race 
horses  that  can  make  twelve-hundred  miles  an  hour  without  getting 
out  of  breath.  The  proof  is  that  they  went  from  Paris  to  Mar- 
seilles in  four  and  a  half  hours.  She  is  very  wealthy,  she  has  a 
million  francs.  When  it  was  pointed  out  to  her  that  a  million  is 
not  so  very  nmch,  she  said  she  had  made  a  mistake,  she  should 
have  said  thirty  million  francs.     At  any  rate  it  is  going  to  be  in- 


GENERAL  PARESIS.  407 

creased  to  one  hundred  and  fifty  million  this  week.  All  this  for- 
tune came  to  her  by  inheritance.  She  also  has  several  hundred 
mansions  which  she  will  convert  into  hospitals.  Everybody  around 
her  shall  be  happy.  The  nurse  who  is  taking  care  of  her  shall 
receive  a  hospital,  a  mansion,  three  broughams,  a  landau,  two 
thoroughbred  horses,  male  and  female,  so  that  they  may  have 
young  ones,  a  race  track,  an  angora  cat,  and  an  estate  with  culti- 
vated grounds.  Another  patient  struck  her  without  provocation; 
"That's  nothuig!  She  shall  have  her  little  million  like  everybody 
else,  just  the  same,  also  a  suit  of  man's  clothes  in  which  she  can 
follow  the  regiments."  —  She  has  two  boys,  "each  twenty  years 
old";  she  herself  is  twenty-five  years  old.  She  had  her  first  child 
at  the  age  of  twelve.  She  states  that  she  drinks  a  good  deal.  In 
all  the  towns  through  which  she  passed  the  station-masters  and 
those  in  charge  of  provisions  gave  her  the  key  to  their  wine 
cellar  in  order  that  she  might  help  herself  at  her  pleasure.  When 
asked  whether  she  could  drink  ten  quarts  of  wine  in  a  day,  she 
exclaimed:  "Ten  quarts!  a  good  deal  more,  at  least  a  barrelful, 
for  I  drink  a  quart  with  every  meal!"  Her  memory  is  greatly 
impaired;  what  little  correct  information  the  patient  gives  is  lost 
in  the  multitude  of  disconnected  pseudo-reminiscences.  —  Physical 
signs:  Distinct  speech  defect  shown  in  her  spontaneous  utterances 
as  well  as  by  test  words.  The  pupils  show  scarcely  any  reaction 
to  light;  they  react  to  accommodation  readily.  Marked  hyper- 
esthesia over  entire  surface  of  the  skin;  the  slightest  pricking 
with  a  pin  causes  marked  pain.  For  several  minutes  during  the 
examination  simple  contact  brought  forth  piercing  cries.  Consid- 
erable loss  of  flesh. 

(B)  Motor  disorders.  —  The  most  frequent  are 
phenomena  of  paralysis  and  of  paresis,  which  may 
assume  the  most  varied  types:  monoplegia,  hemi- 
plegia, facial  paralysis.  The  latter,  generally  slight, 
constitutes  a  very  frequent  and  often  an  early 
symptom. 

The  paralysis  is  either  flaccid  or  associated  with 
contractures. 

A  certain  degree  of  motor  aphasia  is  often  ob- 
served. 


408  MANUAL  OF  PSYCHIATRY. 

Paralysis  in  many  cases  follows  a  seizure  and  is 
usually  transitory. 

Convulsions  will  be  considered  in  connection  with 
epileptiform  seizures. 

Sometimes  choreiform  movements  are  observed  in 
general  paresis  (Vallon  and  Marie),  also  tremors 
analogous  to  those  of  multiple  sclerosis  and  of 
athetosis. 

(C)  Disorders  of  the  reflexes.  —  The  best  known 
and  the  most  important  are  the  changes  in  the  patellar 
reflex. 

There  is  nothing  constant  about  these,  as  they  vary 
not  only  in  different  patients  but  also  in  the  same 
patient  at  different  times. 

The  patellar  reflexes  may  be  normal,  exaggerated, 
diminished,  or  abolished.  Sometimes  they  are  un- 
equal on  the  twp  sides:  one  may  be  exaggerated,  the 
other  abolished. 

Complete  abolition  is  seen  in  the  tabetic  form, 
exaggeration  in  the  spastic  form. 

Other  tendon  reflexes  have  been  but  little  studied. 
It  has  been  noted  that  exaggeration  of  deep  reflexes 
is  generally  more  marked  in  the  upper  extremities. 

As  to  cutaneous  reflexes,  they  are  sometimes  exag- 
gerated, more  often  abolished.  The  Babinski  sign  is 
present  only  in  cases  with  lesions  of  the  pyramidal 
tracts,  especially  in  those  with  combined  sclerosis. 

(D)  Disorders  of  sensation.  —  These  have  been 
well  dos(;ribed  by  Alarandon  de  Montvel,  from  whom 
the  following  facts  have  been  borrowed: 

(a)  Sensibility  to  pain  is  often  diminished,  less  fre- 
quently  abolished,   rarely  Exaggerated.     Some   pa- 


GENERAL  PARESIS.  409 

tients  present  retardation  of  the  perception  of  pain. 
Disorders  of  the  pain  sensibility  often  persist  during 
remissions. 

{b)  Tactile  sensibility  is  usually  normal.  However 
there  may  be  hyperaesthesia,  hyposesthesia,  and  even 
complete  anaesthesia.  These  disorders  disappear 
during  remissions. 

(c)  Special  senses:  disorders  of  hearing  (more  or 
less  marked  deafness,  tinnitus,  etc.)  are  not  infre- 
quent, but  by  reason  of  their  common  occurrence  in 
other  forms  of  insanity  and  in  normal  individuals 
they  are  of  but  slight  importance. 

In  some  cases,  however,  the  deafness  is  of  central 
origin  and  seems  to  be  directly  due  to  the  meningo- 
encephalitis. Recently  I  had  under  my  observation 
a  paretic  who  developed  bilateral  deafness  following 
an  apoplectiform  attack.  At  first  his  deafness  was 
remittent ;  on  some  days  the  patient  could  hear  fairly 
well,  while  on  other  days  he  understood  what  was  said 
to  him  only  by  the  movements  of  the  lips  and,  of 
course,  but  very  imperfectly.  Now  his  deafness  is 
complete. 

Amblyopia  or  even  complete  amaurosis  is  some- 
times encountered.  In  certain  cases  it  depends  upon 
atrophy  of  the  optic  nerve. 

The  senses  of  taste  and  smell  are  often  greatly 
impaired. 

Disorders  of  the  generative  function  are  quite  fre- 
quent and  vary  with  the  stage  of  the  disease. 

The  onset  is  often  marked  by  genital  excitation, 
which,  associated  with  the  mental  enfeeblement,  may 
lead  to  indecent  or  criminal  acts :  exhibitionism,  rape, 


410  MANUAL  OF  PSYCHIATRY. 

etc.  Later  this  excitation  is  replaced  by  absolute 
impotence. 

(E)  Trophic  disorders.  —  These  affect  all  the 
tissues. 

Osseous  tissue:  abnormal  fragility  of  the  bones, 
fractures  caused  by  sUght  traumatisms  or  even  oc- 
curring spontaneously. 

Connective  and  cartilaginous  tissues:  the  trophic 
disorders  are  here  chiefly  manifested  by  hcematoma 
auris,^  which  consists  in  an  extravasation  of  blood 
into  the  tissues  of  the  auricle. 

The  exact  seat  of  the  extravasation  in  Jicematoma 
auris  is  still  a  disputed  question.  Some  are  of  the 
opinion  that  it  is  in  the  subcutaneous  tissues,  others 
beheve  that  it  is  between  the  cartilage  and  the  peri- 
chondrium, and  still  others  think  that  it  is  within  the 
cartilage  itself. 

Manifestations  of  trophic  disorders  are  usually 
favored  by  traumatisms.  It  must  not  be  forgotten 
that  the  great  majority  of  hcematomata  auris  are  on 
the  left  side  and  that  when  one  receives  a  blow  it  is 
usually  on  that  side.  It  is  possible  to  reduce  con- 
siderably the  number  of  hceinatomata  in  asylums  by 
holding  the  attendants  directly  responsible  for  their 
occurrence. 

Skin.  —  Deformity  and  grooving  of  the  nails,- 
diverse  eruptions,  herpes.  The  latter  lesion  indicates 
involvement  of  the  cord  in  the  pathological  process; 

'  Gatian  de  C16rariibault.  Contribution  a  I'ctude  de  V othematome. 
ThfVc  <h  Paris,  1899. 

2  Trovos.  Sii  alcani  altcrdzioni  distrophiclie  ddle  unghi.  Rivist. 
di  din.  medic.,  1899,  No.  6. 


GENERAL  PARESIS.  411 

it  may  constitute  one  of  the  first  symptoms  of  the 
disease. 

The  most  frequent  and  most  grave  cutaneous  dis- 
turbances are  pressure-sores. 

Whether  bilateral  or  unilateral  they  develop  chiefly 
at  the  points  bearing  the  weight  of  the  body  while 
the  patient  is  in  bed;  hence  the  sacral,  gluteal,  and 
trochanteric  bed-sores.  The  sacral  bed-sore  is  very 
often  median. 

In  their  dimensions  they  vary  from  small  sores  of 
the  size  of  a  dime  to  those  exceeding  the  size  of  the 
palm  of  the  hand. 

Their  depth  also  varies  in  different  cases.  Some 
remain  superficial,  while  others  destroy  the  skin,  sub- 
cutaneous tissue,  and  muscles,  and  expose  the  bone. 

Their  course  is  often  progressive;  that  is  to  say, 
they  increase  in  extent  and  in  depth.  Sometimes 
they  heal  under  the  influence  of  appropriate  treat- 
ment. 

Muscles.  — •  Localized  muscular  atrophy  is  rare.  It 
affects  different  groups  of  muscles  and  may  have  one 
of  two  origins,  resulting  either  from  degeneration  of 
the  white  columns  of  the  cord,  which,  in  its  turn,  is 
caused  by  cerebral  lesions  (Grelliere),^  or  from  pri- 
mary degeneration  of  the  cells  in  the  anterior  horns 
(Joffroy),- 

(F)  Visceral  disorders.  —  These  are  dependent 
either  upon  the  disease  itself  or  upon  a  complication. 

'  Grelliere.  Atrophic  musculaire  dans  la  paralysie  generate  des 
alienes.     Paris,  1875. 

2  Joffroy.  Contribution  a  Vanatomie  pathologique  de  la  paralysie 
generate.     Congres  dc  Medecine  mentale,  1892. 


412  MANUAL  OF  PSYCHIATRY. 

It  is  unfortunately  difficult  to  determine  in  any  given 
case  what  the  real  cause  is. 

(a)  Digestive  apparatus:  Its  functions  become  dis- 
turbed chiefly  in  the  terminal  stage  of  all  forms,  and 
early  in  the  depressed  and  excited  forms:  anorexia, 
vomiting,  constipation,  or  intractable  diarrhoea.  In 
the  expansive  form  one  often  notes  a  veritable  bou- 
limia. 

(6)  Cardio-vascular  apparatus:  Evidences  of  ath- 
eroma, myocarditis,  rapid  and  feeble  pulse  in  the 
terminal  cachexia.  Aortic  insufficiency  is  not  rare 
and  is  probably  due  to  syphilis. 

(c)  Kidneys:  Slight  albuminuria  is  frequent.  This 
with  the  low  specific  gravity  of  the  urine  is  an  indica- 
tion of  a  certain  degree  of  renal  insufficiency. 

(d)  Liver:  Sometimes  hypertrophied,  more  rarely 
atrophied  with  phenomena  of  cirrhosis.  The  ascites 
that  usually  accompanies  atrophic  cirrhosis  of  the 
liver  is  generally  absent  in  the  cirrhosis  of  general 
paresis  (Khppel). 

(e)  Respiratory  apparatus:  Congestion,  broncho- 
pneumonia, and  splenization  are  frequent  complica- 
tions of  the  last  stage.  Pulmonary  tuberculosis  is, 
on  the  contrary,  quite  rare  and  usually  runs  a  slow 
course  (Bergonier,  Klippcl). 

(G)  Seizures.'  — ■  These  are  frequent,  occurring  at 
all  periods  of  the  disease  and  often  marking  the  onset. 
They  may  be  fatal.  According  to  Arnaud  death 
from  a  seizure  is  the  natural  mode  of  termination  of 

^  Piorret.  Les  attaqurs  epiUptiformcs  ct  apoplectijormes  dans  la 
paralysie  gcnerale.  Progres  in6clical,  1897.  —  Arnaud.  Arch,  de 
neurol.,  1897.  —  Bonnat.     These  tie  Paris,  1900. 


GENERAL  PARESIS.  413 

general  paresis.  They  are  often  accompanied  by 
elevation  of  temperature  which  is  at  times  consider- 
able. In  some  cases  more  or  less  marked  albmnin- 
uria  is  observed,  which  disappears  several  hours  or 
several  days  after  the  seizure. 

On  recovery  from  these  seizures,  which  is  most 
usual,  symptoms  of  apoplexy  (paralysis,  aphasia) 
often  appear;  they  are  almost  always  transitory, 
there  being  no  gross  lesions  of  the  corresponding  pro- 
jection-centers. The  seizures  are  generally  followed 
by  an  aggravation  of  the  fundamental  mental  and 
physical  symptoms. 

The  seizures  are  of  two  kinds:  apoplectiform  and 
epileptiform. 

The  former  are  characterized  by  more  or  less  com- 
plete loss  of  consciousness  associated  with  complete 
flaccidity  of  the  limbs. 

The  latter  consist  in  general  or  localized  convul- 
sions. The  general  convulsions  sometimes  so  closely 
simulate  epilepsy  as  to  be  mistaken  for  it.  The 
localized  convulsions  assume  the  aspect  of  Jacksonian 
epilepsy  (monocrural,  monobrachial,  facial).  The 
loss  of  consciousness  accompanying  the  partial  con- 
vulsions is  either  complete  or  reduced  to  a  slight 
degree  of  confusion,  as  in  the  case  of  convulsions 
due  to  focal  lesions,  such  as  cerebral  tumor  and 
the  like. 

§  3.   Forms.     Evolution.     Diagnosis. 

The  principal  forms  of  general  paresis  are: 

(A)  The  demented  form; 

(B)  The  expansive  form; 


414  MANUAL  OF  PSYCHIATRY. 

(C)  The  excited  form; 

(D)  The  depressed  form; 

(E)  The  spmal  fonns  j  ^^^^U^J 

(  spastic. 

A.  The  demented  form.  —  This  form  constitutes 
from  the  psychic  standpoint  the  pure  type  of  general 
paresis,  free  from  accessory  symptoms. 

The  onset  is  marked  chiefly  by  indifference  and  loss 
of  memory. 

When  the  disease  is  fully  established  the  symptoms 
are  those  of  profound  mental  enfeeblement,  which  we 
have  already  described,  associated  with  the  charac- 
teristic physical  disorders. 

This  form  is  frequent ;  its  evolution  is  rapid  and  not 
interrupted  by  remissions. 

B.  The  expansive  form.  —  Also  frequent. 
Special  features: 

Euphoria,  often  very  marked. 

Effusive  benevolence,  interrupted  by  transitory 
outbreaks  of  anger. 

Ideas  of  self-satisfaction  and  ideas  of  grandeur 
(hallucinations  are  very  rare). 

Excitement,  loquaciousness. 

The  disease  begins  with  a  morbid  activity  and 
slight  excitement,  which,  associated  with  disorders  of 
judgment,  often  lead  the  patient  to  ruinous  deeds, 
misdemeanors,  and  even  crimes.  Unnecessary  pur- 
chases, absurd  enterprises,  violations  of  decency, 
rape,  and  swindling  are  common.  It  is  this  stage 
that  constitutes  chiefly  the  medico-legal  period  of 
general  paresis. 

The  evolution  of  this  fonn  is  slow.     The  duration 


GENERAL  PARESIS.  415 

of  the  illness  quite  frequently  exceeds  three  years. 
Remissions  are  frequent. 

C.  The  excited  form.  —  This  sometimes  begins 
with  a  state  of  excitement  and  confusion  resembling 
mania  or  acute  confusional  insanity. 

Its  special  features  are: 

Complete  loss  of  orientation  in  all  its  forms; 

Incoherent  delusions,  usually  associated  with  nu- 
merous hallucinations; 

Violent  reactions  with  very  marked  motor  excite- 
ment; 

Profound  disturbances  of  general  nutrition. 

It  may  run  one  of  two  possible  courses:  the  excite- 
ment may  persist  and  death  supervene  within  a  few 
months  or  even  weeks  (galloping  ge'neral  paresis) ;  or 
the  excitement  may  subside  and  the  disease  may  pass 
into  one  of  the  other  forms,  the  demented,  expansive, 
or  depressed. 

D.  The  depressed  form.  —  The  onset  is  marked  by 
a  state  of  depression,  so  that  the  trouble  may  be  mis- 
taken for  involutional  melancholia  or  for  an  attack  of 
manic  depressive  insanity. 

The  special  features  of  this  form  are: 

Psychic  inhibition; 

Psychic  pain; 

Melancholy  delusions; 

Attempts  at  suicide  that  are  frequently  childish 
and  ineffective; 

Peripheral  vaso-constriction,  impairment  of  general 
nutrition; 

Refusal  of  food. 

All  these  disorders,  however,  harmonize  less  per- 


416  MANUAL  OF  PSYCHIATRY. 

fectly  with  each  other  than  in  the  constitutional 
depressive  affections. 

The  evolution  is  very  rapid.  Death  supervenes 
early,  and  is  due  to  cachexia  or  to  some  complication 
(infection  favored  by  the  impaired  nutrition  and  the 
diminished  resistance  of  the  tissues). 

E.  Spinal  forms.  —  Tabetic  form.  —  This  form  has 
at  the  beginning  the  aspect  of  ordinary  tabes.  The 
signs  of  general  paresis  appear  much  later. 

Its  special  features  are: 

Lightning,  lancinating  pains;  girdle  sensation; 

IVIarked  ataxic  symptoms; 

Abolition  of  the  patellar  reflexes; 

Romberg's  symptom; 

Argyll-Robertson  pupil. 

The  s^Tuptomatology  of  this  form  of  general  paresis 
is,  however,  not  identical  with  that  of  pure  tabes. 
The  pains  are  less  severe,  the  urinary  troubles  less 
frequent  (Joffroy).  A  curious  fact  difficult  to  explain 
is  that  as  the  symptoms  of  general  paresis  become 
more  pronounced,  those  of  tabes  (at  least  the  sub- 
jective symptoms)  seem  to  disappear. 

Spastic  form.  {For??!  with  lateral  sclerosis.)  —  This 
form  is  characterized  by  muscular  rigidity,  exagger- 
ation of  reflexes  and  epileptoid  trembling.  The  Ba- 
binski  sign  is  almost  constant.  ''These  symptoms 
are  sometimes  ])ilateral  and  symmetrical,  at  other 
times  unilateral,  and  still  at  other  times,  at  the  onset 
of  the  disease,  mobile  and  variable."     (Dupre.) 

The  different  fonns  above  described  may  follow 
each  other,  or  they  may  be  associated  in  the  most 
varied  ways. 


GENERAL  PARESIS.  417 

Course  and  prognosis. -- The  course  of  general 
paresis  is  progressive,  and  has  been  schematically 
divided  into  three  stages,  not  including  the  prodromal 
stage:  (1)  stage  of  onset;  (2)  stage  of  complete  de- 
velopment; (3)  stage  of  cachexia. 

The  symptoms  at  the  stage  of  onset  are  very  vari- 
able. Generally  mental  symptoms  are  the  first  to 
attract  attention  and  even  to  suggest  the  diagnosis: 
disorders  of  memory  and  orientation;  the  patient 
loses  his  way  in  the  streets  with  which  he  is  most 
familiar,  forgets  on  leaving  the  house  what  he  started 
out  for;  there  are  also  irritability,  outbursts  of  anger, 
attacks  of  depression  or  of  excitement  with  elation; 
more  or  less  active  delusions.  These  symptoms  are 
not  incompatible  with  a  certain  degree  of  mental 
activity;  hence  the  anomalies  of  conduct  leading  to 
antisocial  consequences  which  are  at  times  very  grave 
and  which  have  led  some  (Legrand  du  SauUe)  to 
designate  this  stage  of  the  disease  as  its  medico- 
legal period.  The  patient  forgets  the  most  common 
conventionahties  and  makes  use  of  obscene  language 
in  public  and  in  the  presence  of  his  own  children.  He 
enters  upon  foolish,  ruinous  enterprises,  buys  dozens 
of  umbrellas,  cases  full  of  jewelry,  hundreds  of  copies 
of  the  same  book.  One  patient,  formerly  a  notary, 
ordered  in  one  day  twelve  tigers  from  Bengal, 
"tamed"  in  Hamburg,  five  thousand  pounds  of  tar 
from  Paris,  and  five  hundred  pounds  of  coffee  from 
Port-au-Prince.  Often  a  paretic  will  commit  thefts 
and  frauds,  so  childish  in  character  as  to  suggest  at 
once  serious  mental  disturbance.  Finally  the  pa- 
tient's impulsiveness  may  lead  to  acts  of  violence, 


418  MANUAL  OF  PSYCHIATRY. 

murder,  and,  when  combined  with  genital  excitation, 
as  is  often  the  case,  to  violations  of  decency  and  to 
rape. 

In  this  stage  the  physical  signs  are  generally  not 
fully  developed;  yet  it  is  rare  for  them  to  be  entirely 
wanting. 

The  second  stage,  that  of  complete  development,  is 
the  one  in  which  the  fundamental  symptoms  are  well 
marked  and  the  delusions,  if  they  exist,  are  in  full 
bloom;  yet  the  patient  is  still  able  to  walk  around 
and  to  eat  and  dress  without  assistance.  There  is  in 
this  stage  as  yet  no  loss  of  sphincter  control  except, 
perhaps,  for  occasional  brief  periods. 

The  stage  of  cachexia  is  characterized  by  complete 
physical  and  mental  dilapidation,  by  the  appearance 
of  pressure-sores,  and  by  permanent  loss  of  sphincter 
control. 

The  prognosis  is  fatal.  Death  occurs  from  cachex- 
ia, or  from  some  complication,  or  as  the  result  of  an 
apoplectiform  or  epileptiform  seizure. 

The  average  duration  of  the  disease  is  from  two  to 
three  years.  There  is,  however,  no  fixed  rule  with 
regard  to  this.  In  exceptional  cases  the  disease  lasts 
but  several  months  or  even  weeks  (galloping  general 
paresis);  in  other  cases,  on  the  contrary,  it  is  pro- 
longed for  ten  or  more  years. 

The  progress  of  the  disease  may  be  interrupted  by 
remissions.  Rarely,  except  at  the  beginning,  are  the 
remissions  complete.  Almost  always  the  persistence 
of  a  certain  degree  of  mental  enfeeblement  or  at  least 
of  a  psychasthenic  condition  and  of  physical  signs 
exclude  any  idea  of  true  recovery. 


GENERAL  PARESIS.  419 

Diagnosis.  —  The  fundamental  elements  of  diagno- 
sis are  progressive  intellectual  enfeeblement  en  masse 
and  the  characteristic  physical  signs. 

General  paresis  may,  especially  at  the  beginning, 
when  neither  the  intellectual  enfeeblement  nor  the 
somatic  signs  are  well  marked,  simulate  many  other 
psychoses. 

Lumbar  puncture  is  here  of  great  service.  An  in- 
crease in  the  number  of  lymphocytes  in  the  cerebro- 
spinal fluid  is  almost  constant  in  general  paresis, 
especially  at  the  onset. 

It  is  known  that  lymphocytosis  of  the  cerebro-spinal 
fluid  always  indicates  a  meningeal  inflammatory 
lesion.  Though  its  existence  does  not  point  posi- 
tively to  general  paresis,  yet  it  excludes  all  affections 
ki  which  there  are  no  meningeal  lesions.  Thus  are 
ehminated:  dementia  prsecox,  involutional  melan- 
cholia, manic  depressive  insanity,  epileptic  psychoses, 
alcoholic  psychoses,  and  exhaustion  psychoses. 
Further,  affections  with  a  basis  of  a  simple  process  of 
atrophy,  Uke  senile  dementia,  or  with  a  basis  of  a 
central  lesion  without  meningeal  involvement  (tu- 
mors of  the  centrum  ovale,  hemorrhages,  cerebral 
softening),  are  also  eliminated. 

The  cerebro-spinal  fluid  and  the  blood  may  also 
be  examined  for  the  Wassermann  reaction,  and  a 
positive  result  will  further  narrow  down  the  diagnosis 
to  some  syphilitic  disorder. 

Lange's  colloidal  gold  test,  applied  to  the  cerebro- 
spinal fluid,  gives  a  very  characteristic  reaction  in 
general  paresis:  complete  precipitation  in  the  first 
two,  three,  or  four  tubes,  partial  precipitation  in  the 


420  MANUAL  OF  PSYCHIATRY. 

next  two  or  three,  and  no  precipitation  at  all  in  the 
rest,  5555432100.     (See  p.  130.) 

Noguchi's  butyric  acid  test  and  the  Ross-Jones 
ammonium  sulphate  test  for  globulins  usually  give  a 
positive  result  in  cases  of  general  paresis  and  a  nega- 
tive result  in  other  psychoses.  All  forms  of  menin- 
gitis, however,  also  give  a  positive  result. 

In  the  great  majority  of  cases  in  which  general 
paresis  is  suspected  its  existence  can  be  either 
established  or  excluded  with  complete  certainty  by 
means  of  these  tests.  There  are,  however,  two 
groups  of  cases  which  may  present  extraordinary 
difficulties  of  differentiation;  the  first  consists  of 
psychoses  essentially  of  a  non-syphilitic  nature  occur- 
ring in  combination  with  tabes:  here  one  must  rely 
mainly  on  the  mental  symptoms  for  the  differentia- 
tion, although  it  has  been  said  that  the  colloidal  gold 
test  gives  but  seldom  the  typical  reaction  described 
above  in  cases  other  than  general  paresis  or  tabo- 
paresis ;^  the  second  group  consists  of  cases  of  cerebral 
syphilis:  the  differentiation  of  these  will  be  con- 
sidered in  the  special  chapter  devoted  to  that  condi- 
tion. 

PATHOLOGICAL  ANATOMY.  — ETIOLOGY.  — TEEATMENT. 

We  shall  describe  separately  the  lesions  of  the  en- 
cephalon,  of  the  spinal  cord,  of  the  peripheral  nerves, 
and  of  the  viscera. 

*  D.M.Kaplan.  Scrologn  of  Nervous  and  Menial  Diseases.  Phila- 
delphia and  London,  1914.  —  Swalm  and  Mann.  The  Colloidal 
Gold  Test  on  Spinal  Fluid  in  Paresis  and  Other  Mental  Diseases. 
N.  Y.  Med.  Journ.,  Apr.  10,  1915. 


GENERAL  PARESIS.  421 

Pathological  Anatomy.  —  A.  Encephalon.  —  Dura 
mater:  often  congested,  presenting  occasionally  the 
lesions  of  hemorrhagic  pachymeningitis. 

Pia-arachnoid  and  brain. 

(a)  Macroscopic  lesions. 

(1)  General  atrophy  of  the  brain,  most  marked  in 
the  frontal  and  parietal  lobes,  and  made  evident  by: 

a.   Flattening  of  the  convolutions; 

j8.   Thinning  of  the  cortex; 

7.  Diminution  of  the  weight,  most  marked  in  cases 
of  slow  evolution,  often  very  slight  or  even  absent  in 
cases  of  general  paresis  of  a  very  rapid  course. 

(2)  Thickening  of  the  pia  mater  and  adhesions  be- 
tween it  and  the  cerebral  substance:  stripping  off  the 
pia  causes  a  tearing  away  of  the  cerebral  substance, 
especially  at  the  frontal  and  parietal  lobes. 

(3)  Arteritis  of  the  large  and  medium-sized  cerebral 
vessels:  this  lesion  is  not  a  constant  one. 

(4)  Ependymal  granulations:  the  lining  of  the  ven- 
tricles is  thickly  studded  with  translucent  granula- 
tions, which  are  sometimes  very  minute,  like  a  fine 
powder  sprinkled  over  the  surface,  but  more  often 
coarser,  resembling  grains  of  granulated  sugar. 
Ependymal  granulations  are  fairly  constant  in 
paresis;  outside  of  paresis  they  are  found  only 
exceptionally. 

(6)  Microscopic  lesions.^ 

^  Ballet.  Les  lesions  cerebrates  de  la  paralysie  generate.  Ann. 
m6d.  psych.,  1898.  —  Anglade.  Sur  les  alterations  des  cellules 
nerveuses  dans  la  paralysie  generate.  Ann.  mod.  psych.,  July-Aug., 
1898.  —  Alzheimer.  Histotogische  Studien  zur  Differentialdiagnose 
des  progress.  Paralyse.  Histol.  u.  histopathol.  Arbeiten.  Vol.  I, 
1904. 


422  MANUAL  OF  PSYCHIATRY. 

(1)  Nerve  cells.  —  Their  changes  are: 

a.  In  numbers  and  arrangement:  many  cells  disap- 
pear; the  different  layers  are  more  difficult  to  dis- 
tinguish than  in  the  normal  state  and  appear  to  be 
confounded; 

j8.  In  shape:  the  processes  disappear,  the  angles 
become  blunted,  the  cell-body  tends  to  reduce  itself 
to  a  small,  granular  and  pigmented  mass; 

7.  In  structure:  chromatolysis  —  that  is,  alteration 
and  destruction  of  Nissl's  corpuscles  —  which  causes 
the  cell  to  assume  a  hyaline  aspect  when  the  chro- 
matic substance  is  destroyed,  or  to  present  a  uniform 
coloration  if  stained  by  the  aniline  pigments  when 
this  substance,  reduced  to  a  fine  powder,  is  dissemi- 
nated through  the  entire  cell. 

(2)  Nerve-fibers:  many  are  destroyed,  which  fact 
can  be  demonstrated  by  Pal's  or  Weigert's  hsema- 
toxylin  stain.  The  degeneration  affects  projection 
fibers  as  well  as  association  fibers,  but  more  particu- 
larly the  superficial  tangential  fibers  of  Exner- 
Tuczek. 

(3)  Pia  mater  and  blood  vessels: 

a.  The  pia  mater  is  thickened,  infiltrated  by  nuclei 
representing  proliferating  fixed  connective-tissue  cells 
or  migrating  leucocytes. 

/3.  The  blood  vessels  are  much  more  numerous  than 
normally;  the  walls  are  thickened,  often  showing  hya- 
line or  fatty  degeneration;  the  perivascular  spaces 
are  infiltrated  with  cells.  The  appearance  of  these 
lesions  is  similar  to  those  of  diffuse  cerebral  syphilis.^ 

'  Mahaiin.  Dc  ritnjmrtancc  dcs  lesions  vnsculaires,  etc.  Bullet. 
dv  rAcud.  roy.  de  Med.  de  Belfzique,  July,  1901. 


GENERAL  PARESIS.  423 

Among  the  cells  infiltrating  the  pia-arachnoid  and 
the  adventitial  coats  of  the  cortical  vessels  a  special 
variety  of  cells  occurs,  known  as  plasma  cells,  which 
are  of  great  importance  in  pathological  diagnosis, 
since  they  are  absolutely  constant  in  general  paresis 
and  are  found,  according  to  Nissl,  in  no  other  chronic 
psychosis.  These  cells  are  somewhat  larger  than  the 
ordinary  round  cells,  contain  coarse,  deeply  stained 
granulations  in  their  nuclei,  and  a  relatively  large 
amount  of  finely  granular  protoplasm  which,  in 
specimens  fixed  in  alcohol  and  stained  with  toluidin 
blue,  takes  a  deep  purple  stain. 

(4)  Neuroglia.  —  Proliferation  of  neuroglia-cells  is 
very  frequently  seen;  when  well  marked  it  is  espe- 
cially prominent  in  the  vicinity  of  the  blood-vessels 
(Mahaim).  Scantily  distributed  here  and  there  may 
be  seen  spider-cells  of  abnormal  shape  and  of 
gigantic  size. 

Among  the  most  constant  neuroglial  changes  must 
be  mentioned  the  ependymal  granulations  already  re- 
ferred to  above.  These  are  found  under  the  micro- 
scope to  consist  of  irregular  hillocks  upon  the  lining 
of  the  ventricles,  formed  by  great  proliferation  of  the 
ependymal  glia  cells  which,  instead  of  consisting  of  a 
single  layer,  as  they  do  normally,  are  in  these  hillocks 
piled  up  in  half  a  dozen  or  more  irregular  layers. 

(B)  Spinal  cord.  —  (1)  Nerve  cells:  degenerative 
and  atrophic  lesions  identical  with  those  of  the  cere- 
bral cells. 

(2)  Nerve-fibers.  —  There  are  two  principal  types 
of  lesions  —  the  tabetic  type  and  the  type  of  com- 
bined sclerosis. 


424  MANUAL  OF  PSYCHIATRY. 

(a)  Tabetic  type.  —  The  degeneration  is  localized 
in  the  posterior  columns  and  is  similar  to  the  lesion  of 
tabes;  this  has  led  many  authors  to  look  upon  general 
paresis  and  tabes  as  two  different  locaUzations  of  the 
same  morbid  process.^  ' 

(6)  Combined  sclerosis.  —  The  degeneration  in- 
volves both  the  posterior  and  the  lateral  columns. 
Moreover,  the  process  here  is  more  diffuse  and  affects 
simultaneously  different  systems  of  fibers  (tract  of 
Gowers,  crossed  pyramidal  tract). 

(C)  Peripheral  nerves.  —  The  lesions  of  the  periph- 
eral nerves  consist  in  the  phenomena  of  neuritis 
and  atrophy,  analogous  to  those  encountered  in  tabes 
and  in  alcoholism. 

(D)  Viscera.  —  Three  classes  of  lesions  may  be  dis- 
tinguished in  the  viscera: 

(1)  Lesions  occurring  merely  as  accidental  compli- 
cations: various  infections,  broncho-pneumonia,  tu- 
berculosis. The  latter  is  rare  and  usually  runs  a  slow 
course. 

(2)  Lesions  which  are  the  direct  consequences  of 
the  nervous  disorders.  These  have  been  studied 
exhaustively  by  Klippel,  who  has  termed  them  vaso- 
paralytic  lesions.  They  consist,  according  to  this 
author,  "in  a  high  degree  of  congestion  and  capillary 
engorgement,  capillary  hemorrhages,  and,  by  conse- 
quence, atrophic  degeneration  of  epithelial  tissues."  ^ 

^  Nageotto.     Tdbes  et  Paralysie  generale.     These  de  Paris,  1893. 

^  Klippel.  Lesions  des  jwumons,  du  coeur,  du  foie  et  des  reins 
dans  la  -paralysie  generale.  Arch,  de  m6d.  experim.  et  d'anat. 
path. J  July,  1892.  —  Angiolella.  Lesions  des  pdils  vaisseaux  de 
quelques  organes  dans  la  paralysie  g6nerale.  II  manicomio,  1895, 
Nos.  2  and  3. 


GENERAL  PARESIS.  425 

(3)  Diffuse  vascular  lesions  identical  in  appearance 
with  those  of  the  cerebral  vessels. 

These  lesions  are  met  with  chiefly  in  the  kidneys, 
liver,  and  heart,  and  are  often  associated  with  de- 
generative lesions,  such  as  fatty  or  cirrhotic  liver, 
sclerotic  kidney,  or  degenerated  myocardium. 

Etiology.  —  In  1857  Esmarch  and  Jessen  were  led 
by  the  clinical  histories  of  their  cases  to  conclude  that 
syphilis  was  the  cause  of  general  paresis,  but  their 
view  gained  ground  very  slowly.  In  France  Charcot 
always  rejected  it,  and  Dejerine  wrote  in  1886, 
"Syphilis  is  very  rarely  found  in  the  histories  of 
general  paretics,  and  has  no  influence  on  the  course 
of  the  affection;  when  found  it  is  but  a  coincidence." 
Others  have  held,  with  Joffroy,  that  syphilis  was  a 
strong  factor  favoring  the  occurrence  of  general 
paresis  but  not  an  essential  cause  of  it. 

Case  histories  alone  were,  naturally,  insufficient 
to  establish  the  essential  part  played  by  syphilis  in 
the  etiology  of  general  paresis,  a  history  of  syphilitic 
infection  being  by  no  means  always  obtainable;  but 
the  case  came  to  be  strengthened  on  anatomical 
grounds  by  the  similarity  between  the  lesions  of 
general  paresis  and  certain  syphilitic  lesions. 

In  1897  Krafft-Ebing  presented  at  the  Interna- 
tional Congress  of  Medicine  in  Moscow  further  im- 
portant evidence.  A  physician,  whose  name  was 
not  mentioned,  inoculated  with  syphiUs  nine  general 
paretics  who  had  reached  the  last  stage  of  the  disease 
and  in  whose  history  syphilis  had  not  been  found; 
none  of  these  developed  a  chancre. 

The  advent  of  the  Wassermann  reaction  with  the 


426  MANUAL  OF  PSYCHIATRY. 

generally  positive  finding  either  in  the  blood,  or  in 
the  cerebro-spinal  fluid,  or  in  both,  led  to  the  general 
acceptance  of  the  view  that  in  the  absence  of  syphiUs 
there  can  be  no  general  paresis.  But  the  nature  of 
the  disease  still  seemed  obscure;  especially  perplexing 
was  its  resistance  to  anti-syphiUtic  treatment  in 
contrast  with  other  syphilitic  lesions.  The  disease 
was  held  to  be  a  consequence  and  not  a  direct  mani- 
festation of  syphilis,  a  "  metasyphilitic "  (Moebius) 
or  ''parasyphilitic"  (Fournier)  disorder,  possibly  in 
the  nature  of  an  autointoxication  (Kraepehn). 

Some,  however,  advanced  the  view,  based  on 
various  considerations,  that  general  paresis  was  but 
a  late  and  pecuUar  manifestation  of  still  active 
syphilis.^  Others,  notably  Lambert  and  Dunlap,^ 
have  insisted  that  a  sharp  line  of  demarcation  cannot 
be  drawn  between  general  paresis  and  cerebral  syphi- 
hs  and  have  brought  to  attention  cases  which,  in 
clinical  features  as  well  as  in  post  mortem  findings, 
represent  transition  or  combination  forms. 

The  nature  of  the  relationship  between  syphilis 
and    paresis    was    finally    settled    by    Noguchi    and 


'  Brown kig  and  McKenzio.  On  the  Wasscrmann  Reaction,  and 
cspecialhj  its  Significance  in  Relation  to  General  Paralysis.  Joum. 
of  Mental  Science,  Vol.  LV,  1909.  —  Plaut  and  Fischer.  Die  L-ues- 
Paralyse-Frage.  AUg.  Zeitschr.  f.  Psychiatric,  Vol.  LXVI,  1909.  — 
RosanofT  and  Wiseman.  Syphilis  and  Insanity.  Amcr.  Journ.  of 
Insanity,  Jan.,  1910. 

^  C.  I.  Lambert.  A  Summary  Renew  of  the  Syphilitic  and  Mcta- 
Hyphilitic  Cases  in  152  Consecutive  Autopsies.  N.  Y.  Stat(»  Hosp. 
Bulletin,  Aug.,  1912.  —  C.  B.  Dunlap.  Anatomical  Borderline 
between  the  so-called  Syphilitic  and  MetcLsyphilitic  Disorders.  Amer. 
Journ.  of  Insanity,  1913. 


GENERAL  PARESIS.  427 

Moore,  ^  who  found  the  treponema  pallidum  in  brain 
sections  from  twelve  out  of  a  total  of  seventy  cases 
of  general  paresis  examined  by  them.  This  finding 
has  since  been  confirmed  by  many  observers,  so  that 
general  paresis  is  now  regarded  as  a  lesion  of  syphilis 
affecting  the  brain  and  differing  from  other  intracra- 
nial syphilitic  lesions  by  the  fact  of  its  distribution 
being  mainly  parenchymatous,  that  of  the  others 
being  meningeal,  vascular,  or  interstitial. 

The  clearer  knowledge  thus  gained  of  the  nature 
of  general  paresis  affords  an  explanation  of  its  pecu- 
liar resistance  to  anti-syphilitic  treatment:  the  path- 
ogenic organisms  are  embedded  in  situations  not 
reached  by  the  medication. 

There  is  still  much  in  the  etiology  of  general  paresis 
that  is  not  well  understood.  The  most  important 
question  demanding  an  answer  is.  Why  do  some 
syphilitics  eventually  develop  general  paresis  and 
other  not?  Probably  not  over  five  per  cent  of  syphi- 
Htics  develop  general  paresis. 

In  this  connection  one  thinks,  perhaps,  first  of  all 
of  a  special  predisposition.  The  view  is  often  ex- 
pressed that  an  inherited  neuropathic  constitution 
renders  one  more  liable,  on  contracting  syphilis, 
eventually  to  develop  general  paresis,  this  view  being 
based  on  the  fact  that  in  cases  of  general  paresis  one 
finds  rather  frequently  a  family  history  of  nervous 
or  mental  diseases,  though  not  by  any  means  so  fre- 
quently  as   in   the   constitutional   disorders.     It   is 

1  Noguchi  and  Moore.  A  Demonstration  of  Treponema  Pallidum 
in  the  Brain  m  Cases  of  General  Paralysis.  Journ.  of  Exper.  Med- 
icine, Vol.  XVII,  No.  2,  1913. 


428 


MANUAL  OF  PSYCHIATRY. 


^"1 


i-.'*^J 


FIG.    12.      T'epoi.ima  pallidum  IN  THE   BRAiN  OF  GENERAL  PARESIS 
(Noguchi    and    Moore.) 


GENERAL  PARESIS.  429 

doubtful,  however,  if  this  view  is  really  supported  by 
the  fact  on  which  it  has  been  based,  as  the  latter  is 
quite  susceptible  of  a  different  interpretation,  namely, 
that  syphilis  itself  is  more  Ukely  to  be  contracted  by 
unrestrained,  dissipated,  and  grossly  inmioral  per- 
sons than  by  others,  these  traits  being,  in  their  turn, 
often  among  the  manifestations  of  neuropathic  con- 
stitutions. Thus,  while  a  special  susceptibihty  to 
the  syphiUtic  virus  may  possibly  have  something 
to  do  with  the  development  of  general  paresis,  the 
known  facts  do  not  seem  to  necessitate  the  assump- 
tion that  the  inherited  neuropathic  constitutions  are 
especially  related  to  tliis  susceptibility. 

Another  view  is  that  special  strains  of  the  syphilitic 
organism,  more  virulent  toward  nervous  tissues,  are 
responsible  for  the  development  of  general  paresis 
and,  perhaps,  of  other  lesions  of  the  nervous  system, 
this  view  being  based  on  the  occasionally  observed 
instances  of  conjugal  paresis  and  of  other  instances 
of  general 'paresis  occurring  in  two  or  more  persons 
whose  syphilitic  infection  can  be  traced  to  the  same 
source.  Such  observations  are,  however,  rare  and, 
considering  the  great  prevalence  of  syphilis,  may  be 
explained  as  coincidences. 

That  the  distribution  of  an  organism  which  is  dis- 
seminated by  the  blood  and  lymphatic  circulation 
and  which  is  itself  actively  motile  will  vary  in  differ- 
ent cases  according  to  mere  chance  would  seem  self 
evident;  therefore  it  is  not  surprising  that  some 
cases  of  syphiHs  should  have  liver  lesions,  others 
bone  lesions,  still  others  lesions  of  the  central  nervous 
system,  including  general  paresis,  etc.,  as  their  most 


430  MANUAL  OF  PSYCHIATRY. 

prominent  manifestations.  Yet  factors  other  than 
mere  chance  undoubtedly  play  a  part  in  some  cases. 
Head  injury,  for  instance,  has  been  shown  by  numer- 
ous carefully  studied  cases  to  be  capable  of  starting 
general  paresis  in  a  syphiUtic  person,  acting,  possibly, 
by  opening  a  way  for  the  migration  of  treponemata 
lodged  in  lymph  spaces,  interstitial  tissues,  or  blood 
vessel  walls  into  the  brain  parenchyma.  Alcoholism 
has  also  been  often  mentioned  as  an  exciting  cause  of 
general  paresis,  but  it  is  difficult  to  determine  the 
exact  part  that  is  played  by  it  in  this  connection. 

It  is  a  remarkable  fact  that  in  cases  of  tabes  or  of 
general  paresis  the  syphilis,  during  the  years  prior 
to  the  involvement  of  the  central  nervous  system, 
runs  a  very  mild  course,  often  hardly  furnishing 
evidence  of  its  presence;  secondary  and,  especially, 
tertiary  manifestations  (iritis,  skin  eruptions,  gum- 
mata)  are  either  slight  or  absent;^  and  at  autopsies 
in  cases  of  general  paresis  one  seldom  finds  the  lesions 
ordinarily  observed  in  old  syphilitics,  such  as  endar- 
teritis, arteriosclerosis,  valvular  heart  lesions,  an- 
eurisms, infarctions,  hepatic  cirrhosis,  etc.  It  would 
seem  that  in  the  cases  destined  to  develop  eventually 
tabes  or  general  paresis  there  is  from  the  beginning  a 
special  distribution  of  the  syphilitic  infection.  How- 
ever this  may  be,  the  mildness  of  the  manifestations 
usually  leads  to  neglect  of  treatment,  and  that  may 
almost  certainly  be  said  to  increase  the  danger  of 
tabes  or  general  paresis. 

^  E.  F,  SnydacktT.  Abacncc  of  Iritis  and  Choroiditis  among 
Syphilitics  who  have  become  Tabetic.  Journ.  Amer.  Med.  Aas'n., 
1910. 


GENERAL  PARESIS.  431 

Among  other  factors  in  the  etiology  of  general 
paresis  the  most  important  are  sex,  age,  occupation, 
and  environment. 

Syphihs  being  more  common  in  men  than  in 
women,  general  paresis  too  occurs  more  commonly  in 
men.  Thus,  during  the  year  ending  September  30, 
1914,  there  were  3338  male  and  2927  female  first 
admissions  to  the  New  York  state  hospitals;  among 
them  were  627  male  and  147  female  cases  of  general 
paresis,  i.e.,  18.8%  and  5.0%  of  all  admissions, 
respectively.^ 

The  great  majority  of  cases  of  general  paresis  occur 
between  the  ages  of  30  and  60.  Thus,  of  a  total  of 
774  cases  of  general  paresis  among  the  first  admis- 
sions to  the  New  York  state  hospitals  in  the  year 
ending  September  30,  1914,  but  49,  or  6.3%,  de- 
veloped before  the  age  of  30,  and  but  28,  or  3.6%,  at 
60  or  over.^  Juvenile  and  even  infantile  cases  are, 
however,  sometimes  met  with,  occurring  generally 
on  a  basis  of  inherited  syphihs. 

All  occupations  do  not  equally  predispose  to 
syphilitic  infection  and,  therefore,  to  general  paresis; 
unfortimately  detailed  and  extensive  statistics  are 
not  available.  It  is  well  known  that  army  and  navy 
officers,  traveling  salesmen,  and  railroad  employees 
furnish  a  comparatively  high  proportion  of  cases  of 
general  paresis,  while  the  opposite  is  true  of  CathoUc 
priests;  Krafft-Ebing,  for  instance,  saw  among  2000 
cases  of  general  paresis  not  a  single  one  in  a  Catholic 


^  Twenty-sixth  Annual  Report  of  the  N.  Y.  State  Hospital  Com- 
mission, Albany,  1915. 


432  MANUAL  OF  PSYCHIATRY. 

priest,  while  among  his  cases  of  insanity  in  army 
officers  no  less  than  90%  were  cases  of  general 
paresis.^  Among  women  professional  prostitutes, 
naturally,  furnish  the  highest  proportion  of  cases  of 
general  paresis. 

Syphilis  occurs  much  more  frequently  in  urban 
than  in  rural  environments;  accordingly,  urban  com- 
mmiities  furnish  a  greater  proportion  of  cases  of 
general  paresis.  Thus,  according  to  the  United 
States  Census,  cities  of  100,000  and  over  furnished 
9.6  and  rural  communities  but  1.6  cases  of  general 
paresis  per  100,000  of  the  general  population  among 
the  admissions  to  hospitals  for  the  insane  in  the  year 
1910.2 

F*revention  and  treatment.  —  The  prevention  of 
general  paresis  consists  mainly  in  measures  for  the 
prevention  of  syphilis,  which  have  already  been  dis- 
cussed in  Part  I,  Chapter  VIII. 

Early  and  thorough  treatment  of  every  case  of 
syphilis  has  also  already  been  mentioned  as  a  measure 
for  the  prevention  of  syphilitic  disorders  of  the  cen- 
tral nervous  system.  It  is  true  that  cases  are  known 
which  were  promptly  and  thoroughly  treated  and 
which  nevertheless  eventually  developed  general 
paresis,  l)iit  this  hai:)penod  for  the  most  part  before 
the  introduction  of  salvarsaii.  As  to  the  effective- 
ness of  salvarsan  in  the  prevention  of  general  paresis, 
it  is  as  yet  too  early  to  speak  with  certainty.  Per- 
haps it  will  have  to  be  conceded  that  even  with  the 


'  Quoted  by  Kraopdin.     Psychiainc.     8th  Edition.     Vol.  II. 
*  Insane  and  Fccbk-inindtd  in  Instituiiotts.     1910. 


GENERAL  PARESIS.  433 

aid  of  this  remedy  the  prevention  of  general  paresis  is 
not  to  be  accompUshed  in  every  case  for  the  reason, 
- —  if  for  no  other,  —  that  even  prompt,  vigorous,  and 
persistent  treatment  with  salvarsan  and  other  anti- 
syphilitic  remedies  does  not  by  any  means  result  in 
all  cases  in  a  permanently  negative  Wassermann  re- 
action; yet  extensive  experience  has  already  shown 
that  in  almost  all  cases  salvarsan  causes  the  prompt 
disappearance  of  the  syphilitic  organism  from  all 
lesions  that  are  accessible  to  examination,  which  is 
followed  by  rapid  heahng  of  the  lesions  themselves;  ^ 
and  in  about  half  of  the  cases  the  Wassermann  re- 
action becomes  negative  after  a  period  varying  from 
two  to  ten  weeks  following  one  or  two  injections.^ 
Thus,  although  it  is  as  yet  perhaps  not  possible  to 
prove  it,  it  seems  but  rational  to  conclude  from  the 
above  considerations  that  a  greater  hope  of  prevent- 
ing general  paresis  is  afforded  in  cases  in  which 
prompt  and  thorough  treatment  has  been  carried 
out  than  in  those  in  which  the  treatment  has  been 
more  or  less  neglected. 

When  general  paresis  has  developed  treatment  by 
anti-syphiUtic  remedies,  at  least  as  ordinarily  ad- 
ministered in  cases  of  syphilis,  is  of  no  avail,  being 
apt  even  to  do  more  harm  than  good.  Recently  at- 
tempts have  been  made  to  bring  anti-syphiUtic 
remedies  more  directly  in  contact  with  the  seat  of  the 
lesion  by  administering  them  intraspinally  or  intra- 

^  Neisser  and  Kutznitzky.  Berl.  klin.  Wochenschr.,  1910, 
No.  32.  —  Herxheimer.  Mlinch.  med.  Wochenschr.,  1910,  No.  33, 
—  Spiethoff.     Mlinch.  med.  Wochenschr.,  1910,  No.  35. 

-  I\jomayer.     Berl.  klin.  Wochenschr.,  1910,  Nos.  34,  37,  and  39. 


434  MANUAL  OF  PSYCHIATRY. 

cranially.^  Somewhat  encouraging  results  have 
been  reported, ^  though  it  is  still  very  doubtful  if  a 
permanent  arrest  of  the  process  has  been  brought 
about  in  any  case. 

For  the  rest,  the  treatment  is  merely  sympto- 
matic. An  institutional  environment  seems  to  have 
a  beneficial  influence  in  many  cases,  a  calming  down 
and  general  improvement  being  often  observed  soon 
after  admission. 

Excitement,  insomnia,  suicidal  tendencies,  and 
refusal  of  food  are  to  be  treated  by  the  usual  methods. 

In  the  last  stage  great  care  must  be  taken  to  pre- 
vent the  development  of  bed  sores.  This  is  a  matter 
of  proper  nursing.  The  patient  must  be  kept 
thoroughly  clean  and  dry,  especially  when,  owing  to 
loss  of  sphincter  control  or  to  mental  deterioration, 
he  soils  and  wets  himself  several  times  a  day.  His 
position  in  bed  must  be  changed  frequently  and  sys- 
tematically so  as  not  to  expose  either  one  side  or  the 
other  or  the  back  to  continuous  pressure  and  friction; 
a  pad  may  have  to  be  placed  between  the  knees  or  the 
ankles  in  cases  with  a  tendency  to  contractures.     The 


'  Swift  and  Ellis.  The  Direct  Trentment  of  Sijphilitic  Diseases 
of  the  Central  Nervous  System.  N.  Y.  Mod.  Journ.,  July  13,  1912.  — ■ 
H.  S.  Ogilvio.  The  Intraspinal  Treatment  of  Syp/iilis  of  the  Central 
Nervous  System  by  Salvarsanized  Serutn  of  Standard  Strength.  Journ. 
Amor.  Med.  As,s'n.,  Nov.  28,  1914.  —  D.  M.  Wardnor.  A  Report 
of  Five  Cases  of  Intracran  ial  I iijeclion  of  A  uto-Sero-Salvarsan.  Amer. 
Journ.  of  Insanity,  Jan.,  1915. 

^  G.  S.  Ainsdon.  7'At'  Intraspinal  Treatment  of  Paresis.  N.  Y. 
State  Hosp.  Bulletin,  Fob.  15,  1915.  —  H.  A.  Cotton.  The  Treat- 
ment of  Paresis  and  Tal)es  Dorsalis  by  Salvarsanized  Serum.  Amer. 
Journ.  of  Insanity,  July  and  Oct.,  1915. 


GENERAL  PARESIS.  435 

bed  must  be  made  carefully,  avoiding  unevenness, 
roughness,  or  wrinkles  in  the  bed  clothes.  The  skin 
over  the  parts  that  are  exposed  to  pressure  may  be 
somewhat  protected  by  sponging  with  alcohol,  dry- 
ing, and  dusting  with  talcum  powder.  An  air-  or 
water-bed  may  be  used,  but  will  be  found  hardly 
necessary  where  the  above-mentioned  precautions 
are  carefully  observed.  When  bed  sores  develop 
they  are  to  be  treated  by  frequent  and  careful  clean- 
sing and  protected  by  a  simple  dressing;  the  apph- 
cation  of  a  saturated  solution  of  picric  acid  seems 
often  to  promote  healing. 

Broncho-pneumonia  is  a  common  compUcation  of 
general  paresis  and  is  in  the  majority  of  cases  the  im- 
mediate cause  of  death.  No  doubt  the  general  debiU- 
tating  effect  of  the  disease  renders  the  patient  more 
liable  to  develop  this  complication,  and  the  chances 
are  further  increased  in  the  last  stage  when  difficul- 
ties of  deglutition  develop  and  food  is  apt  to  find  its 
way  into  the  respiratory  passages.  Yet  here  too 
careful  nursing  can  accomplish  a  good  deal,  and  it  is 
safe  to  say  that  the  frequency  of  broncho-pneumonia 
can  be  considerably  reduced.  Demented  patients 
will  not  complain  of  feehng  cold,  and  it  is  the  nurse's 
duty  to  have  the  patient  at  all  times  comfortably 
clad,  well  covered  if  in  bed,  and  protected  against 
draughts;  special  care  must  be  observed  when  the 
patient  has  occasion  to  sit  up  in  his  bed,  or  leave,  his 
bed,  and  in  bathing.  Patients  having  to  take  their 
meals  in  bed  should  be  placed  in  an  easy,  natural 
position,  propped  up  with  pillows,  and  not  so  as  to 
have  to  reach  over  the  side  of  the  bed  to  get  the  food 


436  MANUAL  OF  PSYCHIATRY. 

or  to  have  to  eat  while  partly  reclining;  when  de- 
glutition becomes  difficult  or  uncertain  they  must 
not  be  allowed  to  feed  themselves,  but  must  be  fed 
by  a  nurse  or  attendant  slowly  with  finely  divided 
food. 

There  is  nothing  ordinarily  to  be  done  for  convul- 
sions beyond  protecting  the  patient  against  injury. 
Continued  convulsions  are  sometimes  successfully 
combated  by  a  high  enema  followed  by  the  adminis- 
tration of  30  grains  of  potassium  bromide  and  20 
grains  of  chloral  hydrate  per  rectum,  repeating  the 
dose  in  an  hour  if  necessary. 


CHAPTER  XII. 

CEREBRAL  SYPHILIS. 

The  distinction  between  general  paresis  and  cere- 
bral syphilis  has  already  been  given  in  the  preceding 
chapter,  where  also  attention  has  been  drawn  to 
the  fact  that  cases  have  been  reported  which  seem 
to  constitute  transition  or  combination  forms. 

Cerebral  syphilis  is  not  so  often  met  with  as 
general  paresis,  at  least  in  hospitals  for  the  insane. 
Thus,  of  a  total  of  6265  first  admissions  to  the  New 
York  state  hospitals  during  the  year  ending  Septem- 
ber, 30,  1914,  774  were  cases  of  general  paresis,  and 
but  47  of  cerebral  syphiUs.^  It  is  probable,  however, 
that  some  cases  failed  to  be  included  in  this  number 
having  been  placed  in  the  cerebral  arteriosclerosis 
group. 

Three  types  of  cases  are  usually  distinguished, 
diffuse  meningitic  type,  gummatous  type,  and  en- 
darteritic  type,  the  distinctions  being  drawn  more  or 
less  arbitrarily  and,  of  course,  not  on  the  basis  of 
any  essential  difference  in  the  nature  of  the  patho- 
logical process.  Yet  the  distinctions  are  valuable 
not  only  from  a  scientific  standpoint,  but  also  from 
that  of  prognosis,  as  the  three  types  vary  consider- 
ably in  clinical  course,  reaction  to  treatment,  and 
outcome. 

1  Twenty-sixth  Annual  Report  of  the  N.  Y.  State  Hospital  Com- 
mission, Albany,  1915. 

437 


438  MANUAL  OF  PSYCHIATRY. 

Diffuse  meningitic  tjrpe.  —  Nearly  half  of  all  cases 
may  be  said  to  be  of  this  type.  It  is  apt  to  occur 
comparatively  early  in  the  course  of  syphilis,  as  a 
rule  within  five  years  after  the  initial  lesion.  Its 
onset  is  usually  rai)id,  the  symptoms  reaching  com- 
plete development  in  two  or  three  weeks.  Ana- 
tomically it  is  characterized  by  a  subacute  diffuse 
meningeal  inflammation,  most  marked  at  the  base 
or  even  limited  to  that  region,  with  occasional 
miliary  gummata;  the  pial  blood  vessels  are  the  seat 
of  more  or  less  widespread  and  more  or  less  pro- 
nounced endarteritis;  the  process  may  subside  in 
one  area  while  extending  to  another,  thus  producing 
a  pecuUarly  varying  clinical  picture. 

The  symptoms  are  physical  and  mental.  The 
physical  symptoms,  in  order  of  importance,  are 
headache,  dizziness,  vomiting,  convulsions,  and  evi- 
dences of  cranial  nerve  involvement,  —  amaurosis, 
ptosis,  strabismus,  facial  neuralgia,  hypersesthesia 
or  ansethesia,  facial  paralysis,  impairment  of  the 
sense  of  smell,  and  possibly  deafness;  the  pupillary 
reaction  to  light  and  distance  maj^  be  sluggish  or 
limited  in  excursion,  but  the  Arg^'ll-Robertson  sign 
is  generally  absent;  a  spastic  and  partly  paralytic 
condition  of  the  lower  extremities  with  increased 
knee  jerks  and  bilateral  or  unilateral  Babinski  sign 
is  often  found.  The  mental  symptoms  are  also 
ver>'  important.  *'A  verj^  characteristic  sign  of 
basic  syphilitic  meningitis  is  the  semi-somnolent, 
semi-conscious,  semi-comatose  condition,  in  which 
the  mental  functions  are  more  or  less  obfuscated 
rather  than  obhterated.     The  patients  may  present 


CEREBRAL  SYPHILIS.  439 

a  lethargic,  typhoid,  or  semi-intoxicated  condition, 
from  which  they  can  be  temporarily  roused  —  a  con- 
dition which  is,  however,  frequently  combined  with  a 
purposeless,  hazy  motor  deUrium,  not  of  a  purely 
automatic  character.  Even  in  the  lesser  degrees  of 
obnubilation  of  consciousness,  there  are  certain  cri- 
teria of  special  significance;  thus  a  patient  may  be 
roused  to  more  or  less  correctly  answer  questions  in 
a  slow,  drawling,  dreamy,  sleepy  manner.  He  may 
even  perform  complex  acts  in  response  to  requests 
or  demands,  yet  be  unable  to  respond  to  the  calls  of 
nature,  and  he  passes  urine  and  faeces  in  the  bed,  or 
evacuates  his  excreta  in  the  room.  Occasionally  the 
patient  may  shamelessly  masturbate.  The  mind 
may  again  become  clear  and  he  may  regain  control, 
but  not  infrequently  this  loss  of  control  over  the 
sphincters  persists,  and  this  denotes  usually  a  perma- 
nent state  of  dementia.  The  dementia  of  syphilitic 
brain  disease  is  characterized  by  being  partial  and 
recurring  in  attacks;  it  does  not  alter  the  character 
and  personality  of  the  individual  to  the  same  extent 
as  in  the  dementia  of  general  paresis.  He  preserves 
his  autocritical  faculties  and  is  conscious  of  his  in- 
tellectual deficit,  and  he  is  by  no  means  indifferent 
to  his  mental  and  bodily  condition.  He  may  suffer 
with  loss  of  memory,  especially  of  recent  events,  and 
his  knowledge  of  time  and  place  may  be  defective. 
He  is  subject  to  sudden  fits  of  excitation  with  motor 
restlessness  or  of  depression  with  suicidal  tendencies."^ 

1  F.  W.  Mott.  Syphilis  of  the  Nervous  Syslem.  A  System  of 
Syphilis,  edited  by  D'Arcy  Power  and  J.  K.  Mxirphy,  Vol.  IV. 
London,  1910. 


440  MANUAL  OF  PSYCHIATRY. 

Gummatous  type.  —  This  type  is  comparatively 
infrequent.  It  is  characterized  anatomically  by  the 
presence  of  one  or  more  large  gummata  originating 
in  the  meninges  and  extending  into  the  brain  sub- 
stance. The  physical  symptoms  are  apt  to  be 
those  of  brain  tumor  together  with  hemianopsia, 
aphasia,  convulsions,  hemiplegia,  etc.,  according 
to  the  location  of  the  gummata.  The  mental 
symptoms  are  much  like  those  of  the  diffuse  men- 
ingitic  type. 

Endarteritic  type.  —  This  is  perhaps  the  common- 
est type  of  cerebral  syphilis,  especially  if  we  take 
account  of  the  circumstance  that  many  cases  are 
difficult  to  distinguish  from  cerebral  arteriosclerosis 
and  are  often  classified  as  such.  The  clinical  mani- 
festations are,  in  fact,  essentially  those  of  cerebral 
arteriosclerosis.  Even  post  mortem  the  differentia- 
tion cannot  always  be  made  with  certainty;  the 
characteristic  finding  in  cerebral  syphilis  is  a  pro- 
liferative endarteritis  accompanied  by  more  or  less 
marked  lymphoid  and  plasma  cell  infiltration  of 
the  adventitial  sheaths  and,  perhaps,  patches  of 
similar  infiltration  in  the  pia. 

Various  combinations,  forms  of  the  three  above- 
mentioned  types  of  cerebral  syphilis,  are  found  in 
practice. 

Diagnosis.  —  Cerebral  syphilis  often  has  to  be 
differentiated  from  brain  tumor,  general  paresis,  and 
cerebral  arteriosclerosis. 

In  cases  of  brain  tumor  the  presence  of  the  cardinal 
sjTnptoms  and  focal  s>Tnptoms  and  the  absence  of 
lymphocytosis  in  the  cerebral-spinal  fluid  and  of  the 


CEREBRAL  SYPHILIS.  441 

Wassermann  reaction  both  in  the  blood  and  in  the 
fluid  will  exclude  cerebral  syphilis. 

When  the  chnical  differentiation  from  general 
paresis  is  uncertain,  some  help  may  be  gained  from 
an  examination  of  the  cerebro-spinal  fluid;  the 
Wassermann  reaction  is  positive  in  from  75  to  90% 
of  cases  of  general  paresis  and  in  but  30  or  35%  of 
cases  of  cerebral  syphihs;^  in  the  latter  condition  it 
is  most  apt  to  be  positive  in  cases  of  the  diffuse 
meningitic  type  and  negative  almost  as  a  rule  in  the 
gummatous  and  endarteritic  types;  lymphocytosis 
is  almost  invariably  present  in  general  paresis,  the 
usual  finding  being  from  15  to  50  cells  per  cubic 
millimeter,  while  in  cerebral  syphiUs  it  is  inconstant 
and  extremely  variable  in  degree,  being  very  often 
shght  or  absent  in  the  gummatous  and  endarteritic 
types  and  as  a  rule  extremely  marked  in  the  diffuse 
meningitic  type  —  from  100  to  1500  cells  or  more 
per  cubic  millimeter  ;2  the  typical  reaction  obtained 
in  the  colloidal  gold  test  in  cases  of  general  paresis 
is  not  apt  to  be  obtained  in  cerebral  syphilis,  there 
being,  instead,  as  a  rule,  but  a  slightly  marked  pre- 
cipitation in  the  first  one  or  two  tubes,  a  mere  change 
of  color  in  the  next  two  or  three,  a  more  intense  re- 
action again  in  the  next  one,  two,  or  three  tubes, 
and  no  change  at  all  in  the  remaining  ones  —  the 
so-called  luetic  curve  which  may  be  represented  by 
the  formula,  3321122200.=^ 

^  D.  M.  Kaplan.  Serology  of  Nervous  and  Mental  Diseases. 
Philadelphia  and  London,  1914,  p.  191. 

2  D.  M.  Kaplan.     Loc.  cit.,  p.  157. 

'  Swalm  and  Mann.  The  Colloidal  Gold  Test  on  Spinal  Fluid  in 
Paresis  and  Other  Mental  Diseases.    N.  Y.  Med.  Joum.,- Apr.  10,  1915. 


442  MANUAL  OF  PSYCHIATRY. 

The  test  of  treatment  is  of  value  in  many  cases, 
improvement  or  recovery  under  salvarsan  or  mer- 
cury and  iodides  with  reduction  or  disappearance  of 
the  lymphocytosis  indicating  cerebral  syphiUs  and 
not  general  paresis. 

In  cerebral  arteriosclerosis  the  findings  in  the 
cerebro-spinal  fluid  are  negative,  so  that  a  difficulty 
in  differentiation  arises  only  in  connection  with  those 
cases  of  the  endarteritic  type  of  cerebral  syphilis  in 
which  the  findings  are  likewise  negative,  and  in  such 
cases,  as  already  stated,  the  differentiation  cannot 
always  be  made  with  certainty  even  post  mortem. 
A  history  of  syphilitic  infection  will,  naturally,  turn 
the  probability  toward  cerebral  syphilis.  The  age 
of  the  patient  may  help  in  the  differentiation;  cases 
occurring  in  persons  under  45  are  almost  surely 
syphilitic;  in  persons  between  45  and  60  the  prob- 
ability is  still  strongly  in  favor  of  syphilis;  after  60 
this  probability  diminishes  with  advancing  senility. 

Prognosis.  —  Cerebral  syphilis  is  a  grave  affection; 
untreated  cases  progress  more  or  less  rapidly  with 
tissue  destruction  and  often  a  fatal  termination. 
Treatment,  however,  if  instituted  early  may  result 
in  a  quick  and  perfect  cure;  the  most  favorable  cases 
from  this  point  of  view  are  those  of  the  diffuse 
meningitic  type;  cases  of  the  gummatous  type  are 
often  stubbornly  resistant  to  treatment;  in  most 
cases  of  the  endarteritic  type  recovery  cannot  be 
expected  owing  to  the  tissue  destruction  which 
occurs  early  in  the  course  of  the  disease,  but  some 
relief  may  be  secured  through  abatement  or  arrest  of 
the  syphihtic  process. 


CEREBRAL  SYPHILIS.  443 

Treatment.  —  This  is  that  of  syphilis  in  general. 
The  special  points  to  be  emphasized  in  connection 
with  cerebral  syphilis  are:  (1)  the  treatment  must 
be  intensive  and  instituted  promptly  upon  the  de- 
velopment of  the  symptoms  in  order  to  forestall,  as 
far  as  possible,  tissue  destruction;  (2)  it  should  be 
controlled  by  repeated  examinations  of  the  blood 
and  cerebro-spinal  fluid,  and  it  should  be  persisted 
in  after  clinical  recovery  until  the  findings  in  the 
blood  and  cerebro-spinal  fluid  become  permanently 
negative;  (3)  intra-spinal  medication  may  be  of 
value  in  some  cases  which  have  resisted  other 
methods  of  treatment;  (4)  every  case  in  which  the 
differentiation  between  general  paresis  and  cerebral 
syphilis  has  not  been  made  with  certainty  should  be 
submitted  to  the  test  of  a  thorough  course  of  treat- 
ment; (5)  Horsley  recommends  that  if  improve- 
ment does  not  occur  in  a  case  of  cerebral  gumma 
after  six  weeks'  medicinal  treatment,  the  growth  be 
removed  by  operation. 


CHAPTER  XIII. 

CEREBRAL  ARTERIOSCLEROSIS.* 

Cerebral  arteriosclerosis  is  not  always  of  syphili- 
tic origin,  though  probably  much  more  frequently 
so  than  would  be  indicated  by  clinical  statistics. 

Disease  of  the  arteries  of  the  brain  is  often  found 
at  autopsies  in  cases  which  have  shown  during  hfe 
no  mental  or  nervous  disturbances.  The  occurrence 
of  such  disturbances  is  probably  determined  by  a 
certain  extent  or  degree  of  arterial  disease.  Arterio- 
sclerotic brain  disease  is  but  a  part  of  general  arte- 
riosclerosis, though  not  infrequently  the  process  is 
found  to  be  much  more  marked  in  the  brain  than 
elsewhere. 

The  symptoms  vary  widely  in  different  cases,  de- 
pending chiefly  upon  the  vessel  or  system  of  vessels 
affected. 

Fig.  13  is  a  diagram  of  the  arterial  supply  of  the 
brain  showing  the  circle  of  Willis,  its  branches  and 
their  distribution. 

The  terminal  arterioles  form  two  distinct  systems: 
a  system  of  short  vessels  supplying  the  cortex,  and  a 

1  Binswangor.  Berlin,  kiln.  Wochenschr.,  1894.  —  Alzheimer. 
Allp;.  Zeitsohr.  f.  Psychiatric,  1902.  —  Cowers.  Manual  of  Diseases 
of  the  Nervous  System.  —  Lambert.  N.  Y.  State  IIosp.  Bulletin, 
Vol.  I;  also  in  20tli  Ann.  Report  N.  Y.  State  Commission  in  Lunacy, 
pp.  91  el  seq. 

444 


CEREBRAL  ARTERIOSCLEROSIS. 


445 


Pai"t  of  marginal  convolution. 

Sui>erior  and  middle  frontal  convolutions. 

Upper  part  of  ascending  frontal  convolution. 


Corpus  callosum. 

Gyrus  fornicatuS, 

Inner  surface  of  first  frontal  convolution. 

Upper  part  of  ascendin^^  frontal  convolution, 


Lobus  quadratub  and 

adjacent  outer  surface  of  hemisphei-e. 


Third  frontal  convolution  and  outer  pail 
of  orbital  surface  of  frontal  lobe. 


Ascending  frontal 
convolution. 


Ascending-  parietal  convolution. 
and  lower  part  of  superior 
parietal  convolution. 


Supramarginal  gyrus. 
First  temporal  convolution. 
Part  of  second  temporal  convoluti( 
Angular  gyrus. 


External  occipital  convolution. 
Third  temporal  convolution. 


Inner  and  outer  surfaces 
of  the  occipital  lobe 


FIG.    13. 


446 


MANUAL  OF  PSYCHIATRY. 


system  of  long  vessels  which  penetrate  deeper  and 
supply  the  marrow;  the  ganglionic  vessels  at  the  base 
constitute  a  part  of  the  medullary  system.  The 
manner  of  distribution  of  the  terminal  arterioles  is 
shown  in  Fig.  14. 


FlCi.    14.       (After  Charcot,   from   Gray's   Anatomy.)        I.    LONG    OR    MEDULLARY 
ARTERIES.        2.    SHORT    OR    CORTICAL   ARTERIES. 


Artoriosclerotic  disoaso  may  affect  chiefly  the  large 
vessels  given  off  from  the  circle  of  Willis  or  their 
principal  branches;  or  it  may  affect  chiefly  the 
terminal  arterioles,  either  the  cortical  or  the  medul- 
lary system,  though  the  process  is  hardly  ever 
sharply  limited  to  any  one  system  of  vessels. 


CEREBRAL  ARTERIOSCLEROSIS.  447 

The  manner  in  which  the  nervous  tissues  are 
affected  is  variable.  Narrowing  of  the  lumen  of  a 
vessel  resulting  from  obliterative  endarteritis  brings 
about  atrophy  of  the  nervous  elements,  due  to  re- 
duction of  the  blood  supply,  there  being  at  the  same 
time  hypertrophy  of  the  neuroglia  tissue  (''perivas- 
cular gUosis"  of  Alzheimer);  thickening  of  the  walls 
of  the  smallest  arterioles  and  of  the  capillaries 
C'arterio-capillary  fibrosis")  results  in  atrophy 
through  interference  with  osmotic  processes;  rough- 
ening of  the  intimal  lining  of  the  vessels  results  in 
the  formation  of  thrombi  or  emboli  with  consequent 
infarction  and  softening;  the  brittle  and  weakened 
condition  of  the  vessel  walls  and  aneurismal  dilata- 
tions combined  with  general  rise  of  blood  pressure 
result  in  rupture  and  hemorrhage  with  compression 
and  destruction  of  nerve  tissue  to  an  extent  depend- 
ing upon  the  amount  of  extravasated  blood. 

The  symptoms  of  arteriosclerotic  brain  disease  may 
perhaps  be  most  conveniently  classified  as  follows: 
(1)  systemic  symptoms;  (2)  symptoms  common  to  all 
forms  of  arteriosclerotic  brain  disease;  (3)  symp- 
toms of  occlusion  of  large  vessels  or  their  branches; 
(4)  symptoms  of  affection  of  the  medullary  system 
of  terminal  arterioles;  (5)  symptoms  of  affection  of 
the  cortical  system  of  terminal  arterioles. 

(1)  Systemic  symptoms.  These  will  not  be  dwelt 
upon  in  detail  here  as  they  are  more  properly  a  sub- 
ject of  text-books  of  general  medicine.  As  being 
among  the  most  important  may  be  mentioned :  rigid 
and  tortuous  peripheral  arteries,  increased  blood 
pressure,  pulse  high  in  tension  but  small  in  volume, 


448  MANUAL  OF  PSYCHIATRY. 

increased  area  of  cardiac  dullness,  accentuation  of 
the  aortic  sound,  often  evidences  of  chronic  inter- 
stitial nephritis. 

(2)  Symptoms  common  to  all  forms  of  arteriosclerotic 
brain  disease,  (a)  Physical  symptoms:  headaches,  in- 
somnia, muscular  weakness,  imperfect  muscular 
control,  attacks  of  faintness  or  dizziness,  epilepti- 
form or  apoplectiform  seizures.  (6)  Mental  symptoms: 
diminished  capacity  for  work,  undue  fatigabihty, 
emotional  instability,  states  of  depression  or  anxiety, 
drowsiness;  later  forgetfulness,  disorientation,  and 
general  mental  deterioration;  a  characteristic  feature 
is  the  persistence  of  insight  for  a  long  time. 

(3)  Symptoms  of  occlusion  of  large  vessels  or  their 
branches.  The  symptoms  usually  come  on  sud- 
denly in  the  form  of  a  stroke,  often,  but  by  no  means 
always,  accompanied  by  loss  of  consciousness  lasting 
from  a  few  minutes  to  several  hours  or  even  longer; 
this  may  be  followed  by  a  dazed,  confused,  or  de- 
lirious period  from  which  the  patient  recovers  with 
permanent  symptoms  the  character  of  which  de- 
pends upon  the  location  and  extent  of  the  lesion. 

(a)  Occlusion  of  the  anterior  cerebral  artery  is  un- 
common; the  symptoms  depend  upon  the  point  of 
occlusion  and  upon  whether  the  main  vessel  or  one  of 
its  branches  is  occluded;  there  may  be  no  special 
symptoms,  or  there  may  be  loss  of  the  sense  of  smell 
on  one  side  or  crural  monoplegia. 

(b)  Occlusion  of  the  middle  cerebral  artery  or  of  its 
branches  is  wery  common;  the  characteristic  symp- 
toms for  the  four  branches  respectively  are:  {a) 
motor  aphasia;    (/3)  facial  or  brachial  paralysis,  or 


CEREBRAL  ARTERIOSCLEROSIS.  449 

both;  (7)  astereognosis;  (5)  partial  bilaretal  deaf- 
ness, sensory  aphasia,  possibly  lower  quadrant 
hemianopsia.  Lesions  of  the  right  hemisphere  pro- 
duce no  aphasia  in  right-handed  persons. 

(c)  Occlusion  of  the  posterior  cerebral  artery  has  for 
its  special  symptom  hemianopsia;  this  symptom, 
however,  occurs  only  when  either  the  main  vessel  or 
its  occipital  branch  is  affected. 

(d)  The  cerebellar  arteries  cormnunicate  with  each 
other  by  fairly  free  anastomosis;  for  that  reason 
occlusion  of  one  of  them  may  cause  but  shght  damage 
and  give  rise  to  no  permanent  symptoms;  when  the 
area  of  softening  is  extensive  there  are  apt  to  be 
vomiting,  vertigo,  and  muscular  incoordination.  In 
some  cases  the  lesion  involves  parts  of  the  pons  and 
medulla,  causing  crossed  hemianaesthesia,  loss  of  the 
sense  of  taste,  dysphagia,  and  aphonia,  and  rapidly 
leading  to  a  fatal  termination. 

Occlusion  of  these  vessels  does  not  in  itself  as  a 
rule  cause  marked  general  mental  deterioration 
aside  from  that  which  is  the  characteristic  ac- 
companiment of  states  of  aphasia. 

(4)  Disease  of  the  medullary  system  of  terminal 
arterioles  (^'chronic  subcortical  encephalitis"  of  Bins- 
wanger)  presents  a  characteristic  picture  at  autopsy: 
the  brain  shows  more  or  less  pronounced  atrophy 
which  is  general  but  which  is  apt  to  be  more  marked 
in  irregular  foci;  the  surface  of  the  brain  is  smooth, 
the  cortex,  though  possibly  somewhat  thinned,  is 
otherwise  normal  in  gross  appearance;  the  white 
substance  and  often  the  basal  ganglia  present  on 
section  sUt-like  defects  where  the  nerve  substance 


450  MANUAL  OF  PSYCHIATRY. 

has  disappeared  either  by  gradual  atrophy  or 
through  sudden  infarction;  these  defects  may  be  so 
numerous  that  the  brain  substance,  riddled  with 
them,  presents  a  spongy  appearance  which  has  been 
called  etat  crible;  in  other  cases  there  may  be  but  one 
or  two  of  them  in  each  hemisphere.  The  distribution 
of  the  affection  is  variable;  usually  it  is  bilateral; 
in  some  cases,  however,  it  may  involve  largely  one 
hemisphere,  the  other  being  almost  entirely  spared; 
in  other  cases  the  ganglionic  vessels  are  the  principal 
seat  of  the  affection. 

The  more  striking  clinical  features  of  this  type  of 
cerebral  arteriosclerosis  are  recurrent  epileptiform  or 
apoplectiform  seizures  and  paralyses,  anaesthesias, 
and  mental  deterioration  the  course  of  which  is 
irregularly  progressive,  increasing  with  each  seizure 
and  remaining  stationary  or  even  receding  somewhat 
in  the  intervals;  toward  the  last  the  patients  become 
helpless  owing  to  paralyses,  contractures,  and  pro- 
found dementia. 

In  cases  in  which  the  affection  is  largely  confined 
to  the  ganglionic  vessels  the  dementia  is  but  slight. 
In  such  cases  there  is  a  special  tendency  toward  the 
formation  of  small  aneurisms  which  frequently  burst, 
and  the  resulting  hemorrhage  into  the  basal  nuclei, 
the  internal  capsule,  and  the  lateral  ventricle  gives 
rise  to  the  familiar  clinical  picture  of  cerebral  apo- 
plexy followed  by  hemiplegia,  dysarthria,  etc. 

(5)  Disease  of  the  cortical  system  of  terminal  arterioles 
also  presents  a  characteristic  anatomical  picture. 
The  surface  of  the  cortex  instead  of  being  smooth  is 
irregularly  pitted  with  small  depressions  which  mark 


CEREBRAL  ARTERIOSCLEROSIS.  451 

the  sites  of  atrophy  and  contraction  in  the  regions 
supphed  by  the  cortical  arterioles  th^  lumina  of 
which  have  become  narrowed  or  even  completely 
obstructed.  The  lesion  is  as  a  rule  unequally  dis- 
tributed but  rather  extensive,  so  that  there  is  marked 
general  brain  atrophy.  Microscopically  one  finds 
various  stages  of  chronic  nerve  cell  change:  pig- 
mentary degeneration,  shrinkage,  atrophy;  the 
nervous  elements  in  the  afifected  areas  ultimately 
disappear  and  are  replaced  by  glia  tissue. 

■  Chnically  the  special  feature  here  consists  in  vari- 
ous irritative  phenomena  followed  later  by  loss  of 
function:  tremors,  athetoid  or  choreiform  move- 
ments, various  seizures,  parsesthesias,  and  later 
paralyses  and  anaesthesias.  The  mental  symptoms 
are  apt  to  be  prominent  from  the  beginning:  hallu- 
cinations, agitation,  violent  excitement,  confusion, 
inaccessibility. 

Diagnosis.  —  General  paresis  may  be  closely  simu- 
lated but  can  always  be  excluded  with  the  aid  of 
lumbar  puncture  which  in  cerebral  arteriosclerosis 
regularly  gives  negative  results. 

Acute  syphilitic  endarteritis  affecting  the  brain  ar- 
teries maybe  clinically  indistinguishable  from  cerebral 
arteriosclerosis.  The  differentiation  may  be  made 
with  the  aid  of  the  Wassermann  reaction.  Cases  of 
arteriosclerotic  brain  disease,  even  when  due  to  old 
syphilitic  infection,  usually  give  a  negative  reaction, 
for  in  such  cases  as  a  rule  the  syphilitic  process  is  no 
longer  active,  the  lesions  being  strictly  post-syphilitic. 

The  differentiation  from  senile  dementia  may  be 
difficult  especially  when  the  latter  is  complicated  by 


452  MANUAL  or  PSYCHIATRY. 

more  or  less  marked  arteriosclerosis,  as  is  so  often  the 
case.  It  must  be  borne  in  mind  that  senile  dementia 
has  for  its  basis  a  process  of  atrophy  which  is  wholly 
independent  of  vascular  disease.  Focal  symptoms, 
recurrent  seizures,  persisting  mental  insight,  also 
stationary  condition  and  duration  over  five  years,  all 
point  to  cerebral  arteriosclerosis.  Senile  dementia 
is  but  exceptional  before  the  age  of  60  years,  while 
cerebral  arteriosclerosis  often  begins  at  50  or  even 
earlier. 

The  course  of  cerebral  arteriosclerosis  in  most  cases 
extends  over  a  number  of  years,  even  ten  or  twenty 
years.  It  is  irregularly  progressive,  as  already  de- 
scribed. In  any  case  sudden  death  may  occur  from 
embolism,  apoplexy,  or  from  exhaustion  following 
convulsions.  Kraepelin  speaks  of  a  grave  progres- 
sive form  which  is  characterized  by  rapid  devel- 
opment of  extreme  dementia  and  an  early  fatal 
termination. 

The  prognosis  of  all  forms  of  arteriosclerotic  brain 
disease  is  unfavorable  for  recovery  from  established 
defect  symptoms;  sudden  or  gradual  progress  of  the 
disease  is  to  be  expected  to  occur  sooner  or  later, 
though  the  condition  may  remain  approximately 
stationary  for  months  or  even  years,  especially  un- 
der favorable  conditions. 

The  treatment  is  purely  symptomatic.  Rest, 
freedom  from  worry  or  excitement,  moderation  in 
eating  and  drinking,  abstinence  from  alcohol,  proper 
regulation  of  the  bowels  may  stave  off  progress  of 
the  disease  or  the  occurrence  of  seizures. 


CHAPTER  XIV. 

TRAUMATIC  PSYCHOSES. 

Traumatisms  may  play  a  part  in  the  etiology  of 
psychoses  essentially  of  a  constitutional  nature,  and 
they  have  been  known  to  cause  the  development  of 
general  paresis  in  syphilitic  persons;  it  is  believed 
also  that  they  can  precipitate  an  attack  of  delirium 
tremens  in  an  alcoholic  person.  Such  cases  are  not 
included  here  under  the  designation  of  traumatic 
psychoses,  but  only  those  in  which  the  traumatism 
constitutes  the  essential,  if  not  the  sole,  cause  of  the 
mental  disorder. 

As  already  stated  in  the  chapter  on  general 
etiology,  traumatic  psychoses  are  comparatively  rare 
in  psychiatric  practice:  but  0.6%  of  all  first  ad- 
missions to  the  New  York  state  hospitals  during  the 
year  ending  September  30,  1913,  were  cases  of 
traumatic  psychoses. 

The  immediate  results  of  head  injuries  come  more 
frequently  under  the  observation  of  surgeons  than 
psychiatrists,  and  it  is  interesting  to  note  from  such 
statistics  as  are  available  that  insanity,  or  at  least 
that  which  is  recognized  as  such  by  surgeons,  is  a 
strikingly  rare  complication  of  head  injuries;  thus 
according  to  the  statistics  of  the  medical  report  of 
the  German  army  concerning  the  experiences  of  the 

453 


454  MANUAL  OF  PSYCHIATRY. 

Franco-Prussian  war,  cited  by  Meyer, ^  of  a  total  of 
8985  cases  of  head  injury  only  13  led  to  insanity. 

The  nature  of  the  injury  in  cases  of  traumatic 
psychoses  is  variable:  fractures  with  depression  of 
fragments  and  destruction  of  brain  tissue  by  direct 
violence;  compression  or  brain  tissue  destruction  re- 
sulting not  directly  from  the  injury  but  indirectly 
from  an  intra-cranial  hemorrhage  following  it;  severe 
concussion  in  cases  with  Unear  fracture  without  en- 
croachments on  the  cranial  cavity  or  even  in  cases 
without  fracture;  bullet  wounds,  etc.  Complicating 
infections  naturally  bring  with  them  febrile  or  in- 
fectious deliria  the  manifestations  of  which  it  is 
difficult,  if  not  impossible,  to  separate  from  the 
symptoms  directly  attributable  to  the  injury. 

Many  cases  of  head  injury  undoubtedly  occur 
without  any  considerable  injury  to  the  brain  and 
this  in  part  accounts  for  the  rarity  of  marked  and 
lasting  mental  complications;  yet  it  is  also  true  that 
fairly  extensive  injury  to  the  brain  may  occur 
without  giving  rise  to  such  compHcations.  It  would 
seem  that  mental  symptoms  are  determined  by  the 
diffuse  effects  of  concussion,  compression,  or  bruising, 
rather  than  by  any  special  localization  of  circum- 
scribed lesions. 

The  first  effect  of  a  head  injury  is  a  dazed, 
stunned,  or  completely  unconscious  condition  which 
comes  on  either  immediately  or,  where  due  to  an 
intra-cranial  hemorrhage,  after  an  interval  following 
the  injury.     This  lasts  from  a  few  minutes  to  sev- 

^  Adolf  Meyer.  The  Analomical  Fads  and  Clinical  Varieties  of 
Traumatic  Insanity.    Amer.  Joum.  of  Insanity,  Jan.,  1904. 


TRAUMATIC  PSYCHOSES.  455 

eral  hours,  after  which  consciousness  may  be  fully 
regained  or  the  patient  may  remain  sonmolent  for 
several  days  and  then  recover.  Cases  of  very  severe 
injury  often  die  without  regaining  consciousness. 

Traumatic  delirium.  —  Dehrium  following  head 
injuries  is  observed  either  inmiediately  after  the 
initial  coma  or  stupor  or  after  a  brief  interval  of 
comparative  lucidity.  It  is  characterized  by  rest- 
lessness, which  may  be  sHght  and  readily  controllable 
or  may  become  aggressively  violent,  disorientation, 
disconnectedness  of  utterances,  more  or  less  relevant 
but  peculiarly  absurd  and  irrational  responses,  and 
tendency  to  fabrication;  psycho-sensory  disturb- 
ances may  occur  but  do  not  seem  to  be  as  prominent 
as  in  other  deliria. 

The  possible  terminations  are  death,  complete 
recovery,  and  recovery  with  mental  or  physical 
residuals.  The  duration  of  cases  which  survive 
usually  extends  over  several  weeks,  and  in  some 
cases  convalescence  lasts  for  weeks  or  even  months 
after  the  acute  period  of  the  illness.  In  the  treat- 
ment the  advisability  of  early  surgical  interference 
should  always  be  considered;  not  only  may  an  im- 
mediate amelioration  be  often  produced  by  raising 
depressed  parts  of  bone,  remo\dng  intra-cranial  blood 
extravasations,  etc.,  but  also  some  of  the  possible 
sequelae  may  be  prevented.  The  danger  of  crani- 
otomy is  now  so  slight  that  its  performance  in 
doubtful  cases  would  seem  justifiable  even  merely 
for  exploration. 

Traumatic  neurasthenia.  —  This  is  the  commonest 
of  the  above-mentioned  mental  residuals  which  may 


456  MANUAL  OF  PSYCHIATRY. 

persist  after  recovery  from  traumatic  delirium;  it  is 
also  frequently  found  in  cases  in  which  no  deUrium 
at  all  has  developed  after  the  initial  coma  or  stupor. 
The  condition  has  been  well  described  by  Koppen^ 
as  one  of  irritability,  forgetfulness,  diminished  work- 
ing capacity,  inabihty  to  concentrate  attention,  and 
increased  susceptibility  to  alcohol,  ''The  formerly 
good  natured  or  even  tempered  persons  become 
irascible,  hard  to  get  along  with;  formerly  con- 
scientious fathers  cease  to  care  for  their  family." 
The  forgetfulness  may  be  so  marked  that  "frequently 
everything  must  be  written  down . "  "  These  patients 
are  unable  to  concentrate  their  attention  even  in 
occupations  which  serve  for  mere  entertainment, 
such  as  reading  and  playing  cards.  They  like  best 
to  brood  unoccupied;  even  conversation  is  rather 
obnoxious.  This  point  is  so  characteristic  that  it 
gives  a  certain  means  of  distinction  from  simulation, 
which  as  a  rule  does  not  interfere  with  taking  part 
in  the  conversations  and  pleasures  of  the  ward  and 
playing  at  cards  which  means  as  a  rule  too  much  of 
an  effort  for  the  brain  of  actual  sufferers."  Physi- 
cally there  are  apt  to  be  pain  or  feeling  of  pressure 
in  the  head  and  a  tendency  toward  dizziness.  ''Ex- 
cessive sensitiveness  of  their  head  obliges  them  to 
avoid  all  work  which  is  connected  with  sudden 
jerks;  bending  over  is  especially  troublesome;  and 
there  is  hardly  any  physical  work  in  which  this  can 
be  avoided;  the  blood  rushes  to  the  head,  headache 
increases,    dizziness   sets   in,    and    the   work   stops. 

1  Arch.  f.  Psychiatric,  Vol.  XXXIII.     (Quoted  by  Adolf  Meyer, 

loc.  cil.) 


TRAUMATIC  PSYCHOSES.  457 

Patients  feel  best  when  in  the  open  air,  inactive, 
and  undisturbed." 

Traumatic  epilepsy.  —  In  many  cases  ordinary 
epilepsy  is  wrongly  attributed  to  an  obviously  in- 
adequate traumatism.  However,  the  existence  of 
true  traumatic  epilepsy  is  hardly  to  be  questioned. 
The  seizures  may  be  sUght,  or  partial,  or  Jack- 
sonian,  or  without  complete  loss  of  consciousness, 
or,  on  the  contrary,  exactly  Hke  those  of  idiopathic 
epilepsy;  the  intervals  at  which  they  occur  are 
variable;  they  may  come  on  spontaneously  or  only 
following  physical  exertion,  indulgence  in  alcohol, 
or  febrile  or  gastro-intestinal  ailments.  The  mental 
condition  is  apt  to  be  much  like  the  above  described 
neurasthenia  with  the  addition  of  confused  or  de- 
lirioid  states  occurring  in  connection  with  seizures; 
in  cases  with  frequent  seizures  there  is  apt  to  be  a 
slowly  progressive  deterioration  hke  that  of  idio- 
pathic epilepsy. 

Traumatic  dementia.  —  This  consists  mainly  in 
an  exaggeration  of  the  memory  and  attention  de- 
fects, general  incapacitation,  and  loss  of  interests  of 
the  above  described  traumatic  neurasthenia. 

Aphasia,  deafness,  paralyses,  and  other  neuro- 
logical symptoms,  depending  on  the  localization  of 
the  brain  injury,  may,  of  course,  also  be  observed. 


CHAPTER  XV. 

MISCELLANEOUS  GROUPS. 
DELIRIA  OF  INFECTIOUS  ORIGIN.^ 

The  mental  disorders  which  appear  in  the  course 
of  infectious  diseases  are  brought  about  by  the  com- 
bined action  of  several  factors:  elevation  of  tem- 
perature, congestion  of  the  nervous  centers,  and 
poisoning  of  these  centers  by  microbic  toxins.  The 
most  important  factor  appears  to  be  the  poisoning  of 
the  nervous  centers. 

One  cannot  fail  to  notice  the  striking  clinical 
resemblance  existing  between  the  toxic  deliria, 
properly  so  called,  and  the  infectious  deliria;  in- 
deed the  resemblance  is  so  close  that  without  the 
somatic  symptoms  pecuhar  to  each  condition  it 
would  be  difficult  or  even  impossible  to  make  the 
differentiation.  Notes  on  such  cases  almost  always 
describe  the  same  s^nnptoms :  clouding  of  conscious- 
ness, confusion,  numerous  illusions  and  hallucina- 
tions, motor  agitation. 

Moreover,  the  infection  itself,  independently  of 
hyperpjTcxia  and  probably  of  any  meningeal  lesion, 
may  cause  grave  mental  disorders   (infectious  de- 

'  Klippel  et  Lopez.  Du  reve  et  du  delire  qui  lui  fait  siiite  dans 
les  infections  aigues.  Rev.  de  Psychiatrie,  April,  1900.  —  Desvaux. 
DUire  dans  les  maladies  aigues.     These  de  Paris,  1899. 

458 


DELIRIA  OF  INFECTIOUS  ORIGIN.  459 

lirium  proper)  which  can  only  be  explained  by  a 
toxic  action. 

After  the  description  of  febrile  delirium  I  shall 
say  a  few  words  with  regard  to  infectious  delirium 
proper. 

Febrile  delirium.  —  In  the  mental  disorders  of 
febrile  origin  three  degrees  of  intensity  can  be  sche- 
matically distinguished. 

In  the  shghtest  degree  of  intensity  the  disorder  is 
limited  to  slight  mental  torpor  and  irritability. 

In  the  second  degree  there  is  disturbance  of  ideation. 
The  remarks  of  the  patient  become  disconnected, 
and  are  characterized  by  a  peculiar  monotony  sug- 
gestive of  a  fixed  idea.  Ten  times  in  succession  he 
will  ask  whether  the  cupboard  is  properly  locked,  or 
whether  such  and  such  a  matter  has  been  attended 
to,  or  whether  some  particular  note  has  been  duly 
paid.  At  the  same  time  some  illusions,  chiefly  affect- 
ing vision,  make  their  appearance.  It  seems  to  the 
patient  that  someone  is  in  hiding  behind  the  curtains, 
that  the  furniture  in  the  room  has  assumed  pecuhar 
shapes.  He  does  not  recognize  the  voices  of  those 
about  him  and  confounds  them  with  each  other. 
All  these  phenomena  the  patient  is  more  or  less  con- 
scious of.  He  realizes,  either  spontaneously  or  from 
the  remarks  made  by  those  about  him,  that  he  is 
mistaken,  ''that  he  is  raving,  that  he  no  longer 
knows  what  he  is  talking  about."  He  is  in  a  state 
of  indefinable  uneasiness  and  is  apt  to  become  some- 
what restless,  especially  at  night.  He  feels  ill  at 
ease  in  his  bed,  tosses  from  side  to  side,  asks  to 
get  up. 


460  MANUAL  OF  PSYCHIATRY. 

Finally,  in  the  third  degree  of  intensity  we  have 
true  delirium.  This  consists  essentially  in  more  or 
kss  profound  clouding  of  consciousness  combined  with 
vague  delusions,  multiple  psycho-sensory  disorders,  and 
motor  excitement  which  is  at  times  very  marked. 

The  delirium  is  essentially  variable  and  mobile,  at 
time  pleasant,  at  others  painful;  the  psycho-sensory 
disturbances  are  of  the  combined  form  with  a  pre- 
dominance of  illusions  and  hallucinations  of  sight. 
The  images  and  scenes  follow  each  other  as  in  a 
dream,  of  which  they  seem  to  be  a  continuation 
(dream  delirium).  The  patient  imagines  he  is  in 
the  country,  in  a  theater,  in  a  church;  pompous 
processions  march  past  him  amidst  the  sounds  of 
music  and  the  perfume  of  flowers  and  censers;  he 
converses  with  imaginary  persons,  defends  himself 
against  assassins,  rejects  a  glass  of  milk  offered  him, 
thinking  that  it  is  poison.  Often  under  the  in- 
fluence of  his  hallucinations  he  strikes  at  the  air  and 
attempts  to  get  out  into  the  street  or  to  pass  through 
the  window,  which  he  takes  for  the  door. 

However,  as  during  a  dream,  the  subject  may  by 
a  sudden  and  energetic  call  be  transported  from  his 
imaginary  world  into  the  real  one.  Such  periods  of 
lucidity  are  in  general  but  transitory. 

Often,  chiefly  in  the  beginning  of  all  forms  and 
through  the  entire  course  of  the  mild  forms,  the 
delirium  disappears  in  the  morning  to  reappear  in 
the  evening  and  to  last  during  a  portion  of  the  night. 

The  prognosis  depends  less  upon  the  intensity  of 
the  delirium  than  upon  the  physical  s^inptoms  which 
accompany  it.     As  a  rule  all  febrile  affections  com- 


DELIRIA  OF  INFECTIOUS  ORIGIN.  461 

plicated  by  intense  delirium  should  be  considered 
grave. 

In  fatal  cases  the  delirium  gradually  subsides  and 
coma  replaces  the  excitement. 

Febrile  delirium,  like  acute  alcoholic  intoxication, 
is  an  excellent  criterion  for  judging  the  resistance  of 
the  brain:  the  greater  the  predisposition  to  mental 
disorders  the*  more  likely  it  is  for  delirium  to  occur 
under  such  circumstances.  Like  alcohol,  the  mi- 
crobic  poisons  and  the  toxic  products  of  the  organism 
act  most  readily  upon  brains  the  equilibrium  of 
which  is  least  stable  and  therefore  most  easily  dis- 
turbed. 

The  treatment  is  that  of  the  infectious  disease. 
Strict  watching  is  indicated.  Cold  baths  are  often 
very  efficacious  in  reUeving  the  mental  disorders. 

Infectious  delirium  proper.  —  Kraepelin  and  Asch- 
affenburg  have  described  under  the  name  of  infec- 
tious  delirium  mental  disorders  which  supervene  in 
the  course  of  an  infection  without  the  fever  being 
particularly  intense  or  even  before  any  fever  has 
appeared  {Initialdelirium) . 

Infectious  dehrium  is  met  with  chiefly  in  typhoid 
fever,  in  variola,  and  in  typhus  fever.  The  symp- 
toms sometimes  take  the  form  of  maniacal  excite- 
ment, more  often  that  of  acute  confusional  insanity 
or  of  hallucinatorv  deUrium. 


CHAPTER  XVI. 

MISCELLANEOUS  GROUPS  {Continued). 

PSYCHOSES  OF  EXHAUSTION :    PRIMARY  MENTAL 
CONFUSION,   ACUTE  DELIRIUM. 

Well  described  by  Georget  and  by  Delasiauve 
under  the  name  of  ''Stupidity,"  primary  mental 
confusion  has  only  recently  been  brought  again  into 
prominence  in  French  medical  Uterature  through 
the  labors  of  Chaslin  and  of  Seglas.^ 

The  fundamental  element  of  this  morbid  entity  is 
mental  confusion  which  is  primary,  profound,  and 
constant. 

Essential  symptoms.  —  After  several  days  of  ill- 
defined  prodromata  such  as  headache,  anorexia,  and 
change  of  disposition,  the  disease  sets  in,  manifest- 
ing itself  by  psychic  and  physical  symptoms. 

A.  Psychic  symptoms.  — These  are  the  symptoms 
of  intellectual  confusion,  more  or  less  marked  and 
more  or  less  pure  according  to  the  gravity  of  the 
disease : 

Clouding  of  consciousness; 

Impairment  of  attention; 

Sluggish  and  disordered  association  of  ideas; 

Insufficiency  of  perception; 

Aboulia,  characterized  by  constant  indecision  and 
by  slowness  and  uncertainty  of  the  movements. 

'  Chaslin.  La  confusion  mentalc  'primitive.  —  S6glaa.  Lecojis 
diniques. 

462 


PSYCHOSES  OF  EXHAUSTION.  463 

The  state  of  the  automatic  psychic  functions  varies 
according  to  the  form  of  the  disease :  the  mental  automa- 
tism may  be  relatively  unaffected  (simple  mental  con- 
fusion), exaggerated  (dehrious  mental  confusion),  or 
paralyzed,  like  the  higher  mental  functions  (mental 
confusion  of  the  stuporous  form). 

B.  Physical  symptoms.  —  The  physical  symptoms  are 
constant  and  "  are  the  expression  of  the  general  prostra- 
tion, exhaustion,  and  malnutrition"  (Seglas). 

Loss  of  flesh  is  an  early  and  a  very  marked  symptom. 
It  is  caused  by  insufficient  alimentation,  digestive  dis- 
orders, and  especially  by  defective  assimilation  of  nutri- 
tive matter. 

Fever  sometimes  exists,  chiefly  at  the  onset;  in  some 
cases,  especially  in  the  stuporous  form,  there  may  be 
subnormal  temperature. 

A  small  low  tension  pulse,  feeble  and  at  times  irregu- 
lar heart  sounds,  sluggishness  of  the  peripheral  circula- 
tion, cyanosis  of  the  extremities,  and  oedema  are  among 
the  manifestations  of  the  general  atony  of  the  cardio- 
vascular apparatus. 

The  appetite  is  abolished,  the  tongue  coated;  the 
process  of  digestion  is  accompanied  by  painful  sensa- 
tions ;  constipation  is  often  present  and  is  very  obstinate. 

Frequently  there  is  slight  albuminuria.  The  toxicity 
of  the  urine  is  often  increased,  this  being  dependent  on 
the  presence  of  certain  ptomaines  in  the  urine  (Ballet 
and  Seglas).^ 

'  For  a  bibliography  bearing  on  the  changes  in  the  urine  in  mental 
confusion  and  in  the  psychoses  in  general,  see  Ballet.  Les  psychoses. 
(Article  in  Traite  de  Medecine,  edited  by  Charcot-Bonchard  and 
Brissaud.)     Chapters  on  Melancholia  and  Mental  Confusion. 


464  MANUAL  OF  PSYCHIATRY. 

The  sleep  is  diminished,  often  replaced  by  a  dreamy 
state  analogous  to  that  of  the  infectious  diseases. 

Primary  mental  confusion  may  be  met  with  in  four 
principal  forms,  differing  in  their  gravity  and  in  the 
predominance  of  one  or  another  class  of  symptoms: 

Simple  mental  confusion; 

Delirious  mental  confusion; 

Stuporous  mental  confusion; 

Hyperacute  mental  confusion  (acute  deUrium). 

Simple  mental  confusion,  —  The  essential  symptoms 
which  have  been  enumerated  above  are  encountered 
here  in  their  purest  form.  The  phenomena  of  psychic 
paralysis  are  of  a  moderate  degree  of  intensity  and  the 
automatic  mental  functions  are  unaffected. 

The  patient  is  often  more  or  less  conscious  of  his  con- 
dition; he  observes  that  a  change  has  taken  place  in  him. 
"  I  am  losing  my  head.  .  .  .  My  mind  is  a  blank.  .  .  ." 
He  perceives  his  mental  disabiHty  and  complains  of 
being  unable  to  gather  or  direct  his  thoughts  or  to  evoke 
reminiscences  —  even  of  events  that  have  left  a  very 
strong  impression. 

The  indecision  and  insufficiency  of  perception  bring 
about  a  state  of  constant  bewilderment.  The  patient 
keeps  repeating  the  same  questions  and  the  same  ex- 
clamations: "  Who  is  there? . . .  Who  has  come? . . ,  Who 
are  you?. . .  Everything  around  me  has  changed."  He 
does  not  recognize  his  surroundings,  or  if  he  does,  it  is 
with  uncertainty.  He  is  not  certain  about  the.  identity 
of  those  about  him;  his  bed  appears  queer  to  him,  his 
own  body  seems  to  him  to  be  changed,  scarcely  recogniz- 
able. It  seems  to  him  that  his  personality  is  going 
to  pieces  so  that  he  no  longer  recognizes  himself.     The 


PSYCHOSES  OF  EXHAUSTION.  465 

notion  of  time  is  impaired.  The  patient  cannot  tell 
whether  he  has  been  at  the  hospital  a  day  or  a  week. 
In  other  words  the  patient's  orientation  suffers  in  all 
its  elements:  allopsychic,  autopsychic,  and  temporal. 
The  disorientation  is  generally  more  marked  when 
the  patient  is  away  from  his  habitual  surroundings. 
While,  surrounded  by  famihar  persons  and  objects, 
the  patient  orients  himself  more  or  less  automatically, 
in  a  new  place  he  could  find  his  bearings  only  by  a  series 
of  mental  operations  of  which  he  is  no  longer  capable. 

The  reactions  are  slow,  undecided;  the  movements 
awkward  and  clumsy. 

The  mental  automatism  remaining  intact,  those  men- 
tal operations  which  require  no  effort  and  no  interven- 
tion of  the  -will  can  still  be  properly  performed.  Thus 
one  may  obtain  from  the  patient  a  certain  number  of 
relevant  and  accurate  replies  to  questions  concerning 
his  age,  occupation,  residence,  etc.  But  these  replies  are 
always  given  mechanically;  they  are  brief  and  abrupt, 
and  can  be  elicited  only  by  putting  the  questions  ener- 
getically and  concisely. 

This  simple,  and,  so  to  speak,  schematic  form  of 
primary  mental  confusion  is  uncommon. 

Delirious  form.  —  This  form,  much  more  frequent  than 
the  preceding  one,  owes  its  peculiar  aspect  to  a  more  or 
less  marked  exaggeration  of  the  activity  of  the  mental 
automatism,  which  gives  rise  to:  (a)  flight  of  ideas  and 
incoherence;  (6)  delusions  and  psycho-sensory  disorders ; 
(c)  more  or  less  motor  excitement. 

The  delusions  present  no  systematization,  as  for  this 
at  least  a  relative  lucidity  is  necessary.  They  assume 
different  forms,  which  often  interchange  in  the  same 


466  MANUAL  OF   PSYCHIATRY. 

subject;  ideas  of  grandeur,  transformation  of  the  per- 
sonality, melancholy  ideas,  ideas  of  persecution.  Pain- 
ful delusions  are  the  most  common.  Sometimes  the 
ideas  are  absurd,  hke  those  of  senile  dements  or  of 
general  paretics. 

The  psychosensory  disorders  consist  sometimes  in 
agreeable,  but  more  often  in  painful,  illusions  and  hallu- 
cinations of  all  the  senses,  though  most  often  of  vision 
and  of  hearing.  They  may  combine  so  as  to  create  an 
imaginary  world  which  is  essentially  mobile  and  change- 
able, or,  on  the  contraiy,  they  may  exist  together  with- 
out any  apparent  correlation. 

Occasionally  the  incessant  illusions  and  hallucina- 
tions impart  to  the  patient  a  peculiar  expression.  Most 
cases  described  under  the  name  of  hallucinatory  delir- 
ium should  properly  be  included  in  this  form  of  mental 
confusion. 

The  emotional  tone  is  variable,  governed  to  some  extent 
by  the  delusions.  However,  one  often  finds,  in  spite  of 
very  active  delirium,  a  striking  indifference,  so  that  a 
certain  discord  exists  between  the  delusions  and  the 
emotions. 

The  motor  excitement  is  not  always  due  to  delusions  or 
psycho-sensory  disturbances.  As  in  dementia  pra^cox, 
so  also  in  this  condition  the  patient  may  give  vent  to 
cries  and  motor  discharges  that  are  purely  automatic  and 
without  any  ap})arent  purpose. 

Mental  confusion  of  the  stuporous  form.  —  Here  the 
psychic  paralysis  involves  not  only  the  higher  mental 
faculties,  but  also  the  automatic  psychic  functions. 

The  limbs  are  motionless,  the  eyes  dull,  and  the  face 
expressionless;  the  mouth  may  be  half  open  and  the 


PSYCHOSES  OF  EXHAUSTION.  467 

saliva  dribbling  away  uncontrolled.  The  patient  fails 
to  react  even  to  the  strongest  stimulation,  or  he  may 
react  but  very  feebly. 

Cataleptic  attitudes  with  dilated  pupils  are  frequently 
seen. 

Hyperacute  form  (acute  delirium).  —  This  form  is  char- 
acterized by  special  intensity  of  the  deUrium  and  of  the 
motor  excitement  on  the  one  hand,  and  by  great  gravity 
of  the  general  symptoms  on  the  other  hand. 

The  patient,  attacked  by  numerous  hallucinations, 
either  painful,  or  agreeable  and  accompanied  by  erotic 
tendencies,  becomes  completely  disoriented  and  wildly 
excited:  he  shouts,  sings,  jumps  out  of  bed,  strikes  the 
walls,  and  attacks  those  about  him.  The  eyes  are 
injected,  the  respiration  is  panting,  the  skin  covered 
with  perspiration,  the  temperature  high,  and  the  pulse 
small  and  often  rapid  and  irregular.  These  signs  point 
to  the  general  gravity  of  the  condition.  In  fatal  cases 
the  patient  rapidly  passes  into  coma  and  dies  in  a  few 
days.  In  favorable  cases  the  agitation  gradually 
disappears,  the  patient  regains  his  sleep,  and  recovery 
finally  takes  place;  this  favorable  termination  is  rare. 

Duration,  course,  and  prognosis  of  primary  mental 
confusion.  —  The  duration  of  the  attack  varies  from  sev- 
eral days  to  a  few  months.  The  curve  representing  its 
intensity  is  rapidly  ascendant,  then  it  remains  stationary 
for  some  time  with  some  oscillations,  and  finally  descends 
gradually.  The  period  of  descent  often  presents  irreg- 
ularities On  account  of  recrudescences  of  the  disease, 
which  are  usually  mild. 

Such  is  the  course  of  favorable  cases,  which  fortu- 
nately are  the  most  frequent  (excluding  acute  delirium). 


468  MANUAL  OF  PSYCHIATRY. 

Recovery  is  complete.  But  the  patient's  recollection  of 
the  events  which  have  taken  place  during  his  illness  is 
vague  or  even  absent.  The  period  of  convalescence  is 
protracted. 

Suicide  is  rare  even  in  the  depressed  forms;  the 
aboulia  is  the  patient's  safeguard. 

In  unfavorable  cases  death  occurs  from  collapse  in 
the  hyperacute  form,  and  from  cachexia  or  from  some 
complication  (pneumonia,  subacute  tuberculosis,  in- 
fluenza, infections  following  traumatisms)  in  the  less 
rapid  cases. 

Diagnosis.  —  The  principal  elements  of  diagnosis  are: 
the  appearance  of  mental  confusion  at  the  onset  of  the 
disease;  the  possibility  of  obtaining  correct  replies  to 
simple  and  energetically  put  questions;  the  state  of 
physical  exhaustion,  and  the  existence  of  the  special 
etiological  factors,  which  we  shall  mention  further  on. 

Many  psychoses  may  resemble  primary  mental  con- 
fusion because  they  may  be  complicated  by  secondary 
mental  confusion.  The  points  of  differential  diagnosis 
have  been  indicated  in  the  respective  chapters  de- 
voted to  the  consideration  of  these  psychoses. 

Pathological  anatomy.  —  The  lesions  of  primary 
mental  confusion  are  of  two  kinds:  inflammatory  and 
degenerative.  The  former,  which  are  most  prominent  in 
the  severe  cases,  consist  in  congestion  and  diapedesis 
in  the  nervous  centers.  The  latter  arc  more  constant, 
and  consist  in  degeneration  of  the  nerve-cells,  which 
is  demonstrable  by  Nissl's  method.^ 

'  Ballet  et  Faure.  Contribution  a  I'anatomie  pathologique  de  la 
psychose  polynewitique  et  certaines  formes  de  confusion  mentale 
primitive.     Presse   m6d.,    Nov.    30,    1898.  —  Maurice   Faure.     Sur 


PSYCHOSES  OF  EXHAUSTION.  469 

Etiology.  —  All  factors  capable  of  bringing  about 
rapid  and  profound  exhaustion  of  the  organism  occur 
in  the  etiology  of  primary  mental  confusion:  physical 
and  mental  stress,  painful  and  prolonged  emotions, 
but  especially  grave  somatic  affections.  The  puerperal 
state,  through  the  exhaustion  which  it  entails  as  well 
as  through  the  nutritive  disorders  and  infections  by 
which  it  is  sometimes  complicated;  the  infectious 
diseases  (typhoid  fever,  the  eruptive  fevers,  influenza, 
cholera);  profuse  hemorrhages;  inanition,  etc.,  are 
among  the  causes  frequently  found  in  the  history  of 
the  disease. 

How  is  the  action  of  these  factors  to  be  explained? 
Two  hypotheses  are  possible. 

According  to  one,  that  of  Binswanger,  the  general 
exhaustion  of  the  organism  brings  about  deficient  cerebral 
nutrition  the  clinical  expression  of  which  is  primary 
mental   confusion. 

According  to  the  other,  advanced  by  Kraepelin, 
the  causes  enumerated  above  bring  about  disturbances 
in  the  nutritive  changes  and  determine  the  production 
of  toxic  substances  which,  acting  upon  the  cerebral 
cells,  give  rise  to  an  intoxication  psychosis:  primary 
mental  confusion. 

Perhaps  both  causes  are  at  work  simultaneously.  In 
either  case  exhaustion  constitutes  the  essential  cause 
of  the  affection  and  the  term  "  Exhaustion  Psychosis  " 
is  therefore  perfectly  applicable  to  it. 

Treatment.  —  During  the  entire  acute  period  of  the 
disease  rest  in  bed  should  be  rigorously  enforced. 

les  lesions  cellulaires  corticales  observees  dans  six  cos  de  troubles 
mentaux  toxi-infectieux.     Rev.  neurol.,  Dec.  1899. 


470  MANUAL  OF  PSYCHIATRY. 

Proper  alimentation  is  of  great  importance.  A  re- 
constructive diet  better  tlian  all  medication  sustains 
the  patient's  strength  and  even  calms  the  agitation. 
Milk,  eggs,  chopped  meat,  and  meat-juice  should  form 
the  basis  of  the  diet. 

In  cases  of  sitiophobia  one  must  resort  without 
hesitation  to  artificial  feeding;  these  patients  cannot 
with  impunity  be  allowed  to  fast.  Gastric  lavage 
sometimes  gives  good  results,  even  in  cases  of  acute 
delirium. 

Injections  of  artificial  serum  are  of  great  service  and 
easy  of  application.  The  necessary  apparatus  consists 
chiefly  of  a  glass  funnel,  a  soft-rubber  tube,  and  a 
slender  trochar. 

Ordinarily  300-500  grams  of  Hayem's  serum  [or  of 
normal  saline  solution]  may  be  injected  every  day  or 
every  second  day. 

The  most  important  results  of  this  treatment  are 
elevation  of  the  blood  pressure  and  diuresis.  ^ 

Moderate  physical  exercise,  life  in  the  open  air,  read- 
ing, and  hght  mental  work  for  brief  periods  at  a  time 
accelerate  the  course  of  convalescence. 

*  Cullerre.  De  la  transfusion  Si'reuse  sous-cutame  dans  les 
psychoses  aigucs  avec  auto-intoxication.  Prog.  m(5d.,  Sept.  30,  1899. 
—  Jacqiiin.  Du  serum  artificiel  en  Psychiatric.  Ann.  m^.  psych., 
May- June,  1900. 


CHAPTER  XVII. 

MISCELLANEOUS  GROUPS  {Continued). 

CHRONIC  INTOXICATION  BY  THE  ALKALOIDS, 

§  1.    MOEPHINOMANIA. 

Chronic  intoxication  by  morphine  brings  about  a 
condition  known  as  morphinism.  Morphinism  con- 
stitutes morphinomania  when  the  drug  has  become  a 
necessity  to  the  organism,  so  that  its  suppression 
causes  a  train  of  physical  and  psychical  disturbances 
known  as  the  symptoms  of  abstinence. 

Etiology. — The  study  of  the  etiology  of  morphino- 
mania involves  the  consideration  of  two  distinct  ques- 
tions: (1)  What  individuals  are  apt  to  become  mor- 
phinomaniacs?  (2)  How  does  one  become  a  morphin- 
omaniac? 

(1)  What  individuals  are  apt  to  become  morphino- 
maniacsf 

Morphine  is  no  longer,  as  it  was  formerly,  an  aristo- 
cratic poison  limited  to  the  upper  classes.  ''Even 
rural  populations  are  no  longer  exempt  from  the  con- 
tagion;  and  the  fault  is  chiefly  with  the  physicians."  ^ 

Morphinomania  is  especially  frequent  among  those 
who,  on  account  of  their  profession  or  surroundings, 

'  Chambard.  Les  morphinomanes.  Bibliotheque  medicale 
Charcot-Debove. 

471 


472  MANUAL   OF   PSYCHIATRY. 

can  readily  procure  the  poison;  such  are  physicians, 
their  wives,  medical  students,  pharmacists,  nurses,  and 
laboratory  attendants. 

As  in  the  case  of  alcoholism,  the  character  of  the  soil 
is  here  also  an  important  factor.  The  less  energetic  and 
mentally  stable  the  individual  is  the  more  likely  he  is 
to  yield  to  the  seductive  influence  of  the  poison.  Thus 
we  find  that  morphinomaniacs  are  often  degenerates. 

(2)  How  does  one  become  a  morphinomaniac  f  —  In 
many  ways,  but  chiefly: 

(a)  Through  viedication :  many  subjects  receive  their 
first  injection  for  the  relief  of  some  painful  affection 
as  hepatic  coHc,  neuralgia,  or  tabes. 

(b)  Through  curiosity:  this  occurs  especially  among 
degenerates,  idlers,  individuals  who  are  tired  of  all 
ordinary  pleasures  and  are  longing  for  new  sensations, 
and  whose  unfortunate  tendency  is  still  farther  stimu- 
lated by  the  example  and  proselytism  of  old  mor- 
phinomaniacs. 

(c)  Through  the  craving  for  a  sedative  or  for  relief 
from  mental  suffering:  this  occurs  in  the  overworked 
(soldiers  in  time  of  war  or  young  people  during  difficult 
examinations)  and  in  those  who  are  driven  by  some 
misfortune  or  ill-luck  to  seek  in  morphine  a  consolation 
for  their  sorrows  and  disappointments. 

Doses.  —  The  action  of  the  poison  becoming  less 
effective  in  time,  the  doses  necessarily  increase  more 
or  less  rapidly.  The  maximum  dose  taken  daily  by 
different  patients  varies  greatly.  One  morphinomaniac, 
reported  by  Pichon,  was  in  the  habit  of  taking  nine 
grams  daily.  Most  patients  limit  themselves  to  smaller 
doses.     Of  the  one  hundred  and  twenty  subjects  com- 


CHRONIC  INTOXICATION   BY  THE   ALKALOIDS.    473 

prised  in  the  statistics  of  Pichon  eighty-four  took  from 
0.40  to  1.20  grams  daily. 

The  methods  of  morphinomaniacs.  —  The  places  usually 
selected  for  the  injections  are  the  arms,  forearms, 
thighs,  or  legs;  the  next  in  frequency  are  the  abdomen 
and  the  chest.  Very  frequently  these  regions  are 
covered  with  scars  from  abscesses  caused  by  septic 
injections.  These  scars  constitute,  so  to  speak,  the 
stigma  of  morphinomania  and  often  enable  the  physician 
to  establish  the  diagnosis  in  spite  of  denials  on  the  part 
of  the  patient 

Many  morphinomaniacs  take  their  injections  without 
regularity  or  precaution  and  at  any  opportunity;  others, 
in  true  epicurean  fashion,  select  the  moment  and  con- 
ditions when  they  can  enjoy  most  profoundly  their 
favorite  pleasure.  Some,  again,  have  their  hours  regu- 
larly fixed,  use  only  accurately  prepared  solutions  of  a 
certain  strength,  and  take  all  antiseptic  precautions; 
many  take  their  daily  quantity  in  divided  doses;  others 
take  a  single  large  dose  daily  in  order  to  obtain  the 
most  intense  effect. 

SYMPTOMS    AND   EVOLUTION. 

According  to  Chambard  four  periods  may  be  dis- 
tinguished in  the  career  of  a  morphinomaniac,  which 
succeed  each  other  by  imperceptible  transitions. 

First  period :  initiation  or  euphoria.  —  It  has  been  aptly 
called  the  honeymoon  of  the  morphinomaniac.  Under  the 
influence  of  the  morphine  physical  pains,  if  they  exist, 
disappear  or  become  abated,  the  organic  functions 
become  more  active,  and  the  mind  lapses  into  a  pleasant 
reverie;  ideas  form  themselves  without  any  effort  and 


474  MANUAL  OF  PSYCHIATRY. 

combine  "to  form  ingenious  conceptions,  elaborate 
resolutions,  vast  projects  which,  alas,  are  never  likely 
to  last  through  the  day";  depressing  thoughts  disappear 
and  life  assumes  a  smiling  aspect. 

This  euphoria  is  identical  with  that  which  is  produced 
by  opium  and  of  which  Thomas  De  Quincey  has  given 
such  an  enthusiastic  description: 

"  O  just,  subtle,  and  all-conquering  opium!  that,  to  the  hearts  of 
rich  and  poor  alike,  for  the  wounds  that  will  never  heal,  and  for  the 
pangs  of  grief  that  *  tempt  the  spirit  to  rebel,'  brings  an  assuaging 
balm;  —  eloquent  opium!  that  with  thy  potent  rhetoric  stealest 
away  the  purposes  of  wrath,  pleadest  effectually  for  relenting  pity, 
and  through  one  night's  heavenly  sleep  callest  back  to  the  guilty 
man  the  visions  of  his  infancy,  and  hands  washed  pure  from  blood; 
—  O  just  and  righteous  opium!  that  to  the  chancery  of  dreams 
summonest,  for  the  triumphs  of  despairing  innocence,  false  witnesses, 
and  confoundest  perjury,  and  dost  reverse  the  sentences  of  unright- 
eous judges;  —  thou  buildest  upon  the  bosom  of  darkness,  out  of  the 
fantastic  imagery  of  the  brain,  cities  and  temples,  beyond  the  art 
of  Phidias  and  Praxiteles,  beyond  the  splendours  of  Babylon 
and  Hekatompylos ;  and,  'from  the  anarchy  of  dreaming  sleep,' 
callest  into  sunny  light  the  faces  of  long-buried  beauties,  and  the 
blessed  household  countenances,  cleansed  from  the  '  dishonours  of 
the  grave.'  Thou  only  givest  these  gifts  to  man;  and  thou  hast  the 
keys  of  Paradise,  O  just,  subtle,  and  mighty  opium!  " 

Second  period :  hesitation.  —  Many  subjects,  conscious 
of  their  danger,  make  efforts  to  escape  from  it.  They 
diminish  the  doses,  reduce  the  number  of  injections,  etc. 
Some  even  completely  discontinue  the  use  of  the  drug 
permanently  or  temporarily. 

The  period  of  hesitation  is  not  constantly  present; 
many  patients  by  reason  of  their  ignorance  or  lack  of 
determination  pass  directly  from  the  first  period  to 
the  third. 

Third   period :   morphinomania  proper.  —  The   poison 


CHRONIC  INTOXICATION  BY  THE  ALKALOIDS.    475 

has  now  impressed  its  stamp  upon  the  organism  and  has 
established  certain  permanent  symptoms.  Moreover,  its 
suppression  gives  rise  to  a  series  of  characteristic 
phenomena,  the  symptoms  of  abstinence. 

(A)  Permanent  symptoms. — (a)  Psychic  phenom- 
ena. —  These  consist  in  a  general  weakening  of  psychic 
activity,  and  are  manifested  in  the  intellectual  sphere 
by  sluggishness  of  association  and  impairment  of  atten- 
tion contrasting  with  intact  orientation  and  perfect 
lucidity,  and  by  retrograde  amnesia  of  reproduction; 
representations  are  in  some  way  inhibited  but  not 
destroyed. 

In  the  emotional  sphere  there  are  indifference  and 
atrophy  of  the  moral  sense.  All  the  aspirations  of  the 
patient  reduce  themselves  to  a  single  idea,  that  of  pro- 
curing morphine  by  any  possible  means;  disregard  for 
conventionalities,  swindling,  falsehoods,  violence,  all 
seem  to  him  permissible.  Many  morphinomaniacs  ob- 
tain their  morphine  from  the  druggist  on  false  pre- 
scriptions, others  sell  their  household  articles  to  pur- 
chase morphine  for  the  money. 

In  the  sphere  of  the  reactions  there  is  always  very 
marked  aboulia.  The  patient  is  conscious  of  the  ruin- 
ous results  of  his  inacti\'ity,  but  has  not  the  power  to 
overcome  it.  This  symptom  appears  early  and  together 
with  the  indifference  forms  a  characteristic  feature  of 
the  mental  state  in  morphinomania. 

(b)  Physical  symptoms.  —  The  general  nutrition  always 
suffers:  loss  of  flesh,  pallor  of  the  skin,  etc. 

The  circulatory  apparatus  shows  general  atony.  The 
cardiac  impulse  is  weak;  the  peripheral  circulation  is 
sluggish;  there  are  transient  oedemas. 


476  MANUAL   OF   PSYCHIATRY. 

The  temperature  is  often  subnormal.  A  case  of  mor- 
phine fever  has,  however,  been  reported  (Levinstein). 

Motility:  general  muscular  asthenia;  a  tendency  to 
fatigue;  tremors:  "slow,  regular  oscillations  resulting 
from  a  twisting  movement  of  the  limb  upon  itself."  ^ 

Sensibility:  slight  hyperaesthesia  which  is  at  times 
unilateral;  diminution  of  the  acuteness  of  vision,  often 
dependent  upon  "  pallor  of  the  optic  disc,  which  may 
advance  to  atrophy."  ^ 

The  pupils  are  frequently  myotic. 

The  tendon  reflexes  are  occasionally  diminished. 
.  (B)  Symptoms  of  abstinence.  —  When  the  hour  for  his 
injection  has  passed  the  morphinomaniac  becomes  rest- 
less, his  expression  becomes  anxious,  and  his  respirations 
accelerated.  A  state  of  anxiety  soon  appears,  accom- 
panied by  a  very  marked  inhibition  of  all  the  psychic 
functions.  The  patient  abandons  his  unfinished  work 
or  conversation  and  leaves,  complaining  that  he  is 
unable  to  bear  the  tortures  of  which  he  is  a  victim.  At 
the  same  time  there  is  the  appearance  of  the  pathogno- 
monic somatic  symptoms:  extreme  pallor  of  the  face, 
acceleration  and  weakening  of  the  pulse,  general  pros- 
tration, cold  sweats,  and  spells  of  yawning.  If  absti- 
nence continues  the  condition  may  become  alarming: 
obstinate  diarrhoea  appears  and  collapse  is  threatened. 

No  matter  how  grave  the  symptoms  become  an  injec- 
tion of  morphine  always  affords  instantaneous  relief. 

Occasionally  the  mental  symptoms  present  all  the 
features  of  a  veritable  acute  psychosis:  agitation, 
anxiety,    persecutory    ideas,    psycho-sensory    disorders, 

*  Jouet.     Quoted  by  Chainbard,  loc.  cit. 
^  Pichoii.     Le  morphinisme,  1890. 


"CHRONIC  INTOXICATION  BY   THE  ALKALOIDS.    477 

excitement  simulating  that  of  mania;  these  may  be 
associated  with  hysteriform  or  epileptiform  attacks. 

Fourth  period:  cachexia.  —  The  symptoms  of  the 
preceding  period  become  more  marked.  The  psychic 
disaggregation  in  some  cases  resembles  true  dementia. 
The  craving  for  the  drug  is  greater  than  ever.  Loss 
of  flesh  reduces  the  patient  almost  to  a  skeleton;  the 
stomach  rejects  all  food  and  a  permanent  and  intrac- 
table diarrhoea  sets  in;  the  blood  pressure  becomes 
low,  the  cardiac  impulse  grows  weaker  and  weaker, 
the  pulse  becomes  small,  thready,  and  irregular;  renal 
changes,  which  are  frequent,  give  rise  to  albumi- 
nuria. 

Numerous  complications  are  apt  to  appear,  render- 
ing the  prognosis  still  more  serious:  pulmonary  tu- 
berculosis, furunculosis,  phlegmons  hasten  the  fatal 
termination,  which  occurs  at  the  end  of  the  fourth 
period. 

Associated  intoxications.  — The  intoxicants,  the  abuse 
of  which  is  often  associated  with  morphine,  are  chiefly 
ether  and  cocaine.  Cocainomania  will  be  made  the 
subject  of  a  special  section.  Ether,  absorbed  from  the 
respiratory  tract  or  from  the  digestive  passages,  brings 
about  a  state  of  euphoria  analogous  to  that  produced 
by  morphine.  In  certain  cases  there  is  a  period  of 
excitement  which  may  reach  the  intensity  of  delirium 
and  which  is  followed  by  comatose  sleep. 

Treatment.  —  Its  aim  is  discontinuance  of  the 
morphine.  This  may  be  attained  by  three  methods: 
the  sudden  method  (Levinstein),  the  rapid  method 
(Erlenmeyer),  and  the  gradual  method  (the  so-called 
French  method). 


478  MANUAL   OF   PSYCHIATRY. 

The  suppression  of  morphine  or  demorphinization 
cannot  be  carried  out  outside  of  a  sanitarium  for  the 
following  two  reasons:  (1)  because  the  patient  should 
be,  in  case  of  threatened  collapse,  within  immediate 
reach  of  medical  aid;  (2)  because  only  strict  super- 
vision can  prevent  the  patient  from  procuring  the  drug 
clandestinely. 

The  method  of  choice  is  rapid  suppression.  "It  is 
a  fact,  recognized  to-day  by  all  physicians  experienced 
in  the  treatment  of  morphinomania,  that  rapid  sup- 
pression is  the  best  method  of  treatment."  ^  The 
period  of  demorphinization  lasts  from  five  to  twelve 
days.  The  principle  consists  in  diminishing  the  dose 
each  day  by  one  half  of  that  administered  on  the  pre- 
ceding day,  and  finally,  on  reaching  a  minute  ration, 
completely  suppressing  the  drug.  It  is  in  the  latter 
days  of  the  suppression  that  the  symptoms  of  abstinence 
appear  with  the  greatest  intensity.  Patients  who 
descend  without  much  difficulty  from  one  gram  or 
more  to  several  centigrams  experience  grave  disturb- 
ances when  they  are  deprived  of  this  minute  allowance. 

Adjuvant  therapy. — -The  diet  should  be  tonic  and 
reconstructive.  In  the  cases  of  marked  cachexia  it  is 
advisable  to  improve  the  state  of  the  general  nutrition 
before  complete  demorphinization. ^ 

The  digestive  tract  and  the  heart  demand  special 
attention. 

Gastro-intestinal  disorders  may  be  prevented  by  tlie 


'  Sollier.  La  (limorjjhi/nzafion.  Presse  m6dicale,  April  23  and 
July  6,  1898. 

'  Joffroy.  Traitcmenl  <le  la  morphinomanie.  Gaz.  hebd.  de  M<id. 
et  de  ('lanir<rio,  1899  and  1900. 


CHRONIC  INTOXICATION   BY  THE  ALKALOIDS.    479 

use  of  bicarbonate  of  soda  (2-6  grams  daily),  and  cardiac 
failure  by  heart  stimulants,  such  as  caffein,  strophan- 
thus,  and,  if  necessary,  digitalis. 

A  morphinomaniac  cannot  be  considered  recovered 
until  a  long  time  has  elapsed  after  the  suppression  of 
the  drug.  The  return  to  ordinary  life  is  for  him  a  critical 
moment;  for  this  reason  isolation  in  a  sanitarium 
should  be  continued  for  several  weeks  after  the  last 
injection. 

This  prolonged  detention  is  further  justifiable  by 
the  grave  complications,  notably  fatal  epileptiform 
attacks,  which  may  occur  long  after  complete  demor- 
phinization. 

In  spite  of  all  these  precautions  permanent  cures  are 
the  exception  and  relapses  are  the  rule. 

§  2.    COCAINOMANIA. 

It  seems  that  cocainomania  first  appeared  in  1878, 
when  Bentley  made  the  fatal  suggestion  of  treating 
morphinomania  by  means  of  injections  of  cocaine. 

Like  morphine,  cocaine  produces  immediately  after 
its  absorption  a  pecuHar  state  of  euphoria  characterized 
chiefly  by  a  sense  of  vigor  and  energy.  The  craving 
becomes  established  after  the  first  few  injections, 
much  sooner  than  in  the  case  of  morphine. 

I  shall  describe  successively  the  habitual  mental 
state  of  the  cocainomaniac  and  cocaine  delirium. 

Habitual  state.  —  Normal  activity  is  replaced  by 
indolence,  and  affectivity  by  indifference.  All  the 
faculties  are  dulled.  The  memory  is  paralyzed,  there 
being  both  anterograde  amnesia  by  default  of  fixation 
and    retrograde   amnesia    by    default    of   reproduction. 


480  MANUAL  OF   PSYCHIATRY. 

The  mood  is  usually  sad,  gloomy,  and  pessimistic,  the 
will  power  is  nil. 

This  state  of  general  enfeeblement  is  interrupted  by 
sudden  outbreaks  of  gaiety  and  feverish  activity,  which 
disappear  very  soon,  leaving  behind  them  an  intensified 
psychasthenia. 

The  sensory  organs  are  the  seat  of  hypercesthesia,  so 
that  even  slight  excitation  produces  pain.  At  intervals 
hallucinations  appear,  which  constitute  the  germ  of 
the  delirium  proper.  Conscious  in  the  beginning,  the 
hallucinations  are  later  accepted  by  the  subject  as  real 
sensations. 

The  general  nutrition  is  poor.  The  skin  assumes 
an  earthy  color;  the  weight  is  reduced;  the  process  of 
digestion  is  sluggish  and  painful;  and  there  is  diarrhoea 
alternating  with  constipation. 

Cocaine  delirium.  —  It  is  a  delirium  of  a  painful 
character  associated  with  delusional  interpretations; 
its  main  features  consist  in  psycho-sensory  disorders 
which,  in  spite  of  their  extraordinary  distinctness,  are 
coexistent  with  perfect  lucidity.  The  illusions  and  hallu- 
cinations may  affect  all  the  senses,  but  especially  vision, 
touch,  and  the  muscular  sense. 

Objects  change  their  shapes  and  arc  constantly 
moving.  A  patient  of  Saury's  *  felt  himself  assailed 
by  a  swarm  of  bees  which  he  could  see  and  feel.  Many 
cocainomaniacs  feel  worms  creeping  over  their  bodies 
or  coming  out  of  their  flesh;  they  see  them,  seize  them 
with  their  fingers,  and  crush  them  under  their  feet. 
Many  also  perceive  imaginary  movements:  the  ground 

1  Saury.     Cocainomanie.     Ann.  m6d.  psych.,  1889. 


CHRONIC   INTOXICATION   BY  THE  ALKALOIDS.  481 

shakes  beneath  them,  their  bed  is  upset,  or  the  house 
they  are  in,  swept  by  a  flood,  floats  upon  the  waves. 
Hallucinations  of  hearing,  taste,  and  smell,  though  not 
rare,  occur  less  frequently  than  the  preceding  and  pre- 
sent no  special  characteristics. 

Sometimes  the  delusions  assume  the  form  of  morbid 
jealousy,  as  in  alcoholic  insanity. 

The  reactions  of  the  patient  are  governed  by  the 
delusions  and  are  often  violent. 

The  duration  of  the  attack  is  brief,  several  weeks  at 
the  longest,  and  in  some  cases  but  a  few  days.  I  have 
seen  a  typical  case  of  cocaine  delirium  terminate  in 
forty-eight  hours. 

The  treatment  consists  in  suppression  of  the  poison, 
which  can  in  the  great  majority  of  cases  be  accom- 
plished by  the  sudden  method  without  serious  incon- 
venience. 


CHAPTER  XVIII. 

MISCELLANEOUS  GROUPS  (Continued), 

PSYCHOSES  OF  AUTOINTOXICATION:   UREMIC 
DELIRIUM. 

Uremic  delirium  presents  the  usual  features  of 
toxic  deliria:  more  or  less  complete  clouding  of  con- 
sciousness, disorientation,  phenomena  of  psychic  autom- 
atism, among  which  psycho-sensory  disorders  occupy  a 
prominent  position. 

The  delusions,  the  emotional  tone,  and  the  reactions 
enable  us  to  distinguish  two  principal  forms  of  urajmic 
delirium:   an  expansive  form  and  a  depressed  form. 

Expansive  form. — The  patient  is  a  great  personage,  a 
general,  a  prince;  he  assists  at  a  grand  review,  gives 
commands  to  his  officers,  or  orders  sixteen  horses  to  be 
harnessed  to  his  carriage;  the  Pope  presents  him  with 
the  imperial  crown. 

Often  the  delirium  takes  a  mystic  form:  the  heavens 
open,  celestial  music  is  heard,  or  angels  descend  on  an 
immense  ladder  as  in  Jacob's  dream. 

Depressed  form. — Melancholy  ideas  combine  with  ideas 
of  persecution  and  hallucinations  of  an  unpleasant 
character.  The  patient  imagines  peo])le  are  searching 
for  him  to  drag  him  to  the  scaffold;  the  house  is  on 
fire;   an  odor  of  sulphur  is  diffused  through  the  air. 

482 


PSYCHOSES  OF  AUTOINTOXICATION.  483 

Whatever  the  form  of  dehrium,  the  reactions  are 
often  very  powerful  and  give  rise  to  violent,  at  times 
terrible,  agitation.  Often,  also,  in  the  depressed  and 
mystic  forms,  there  is  marked  stupor  with  a  tendency 
to  cataleptoid  attitudes.^ 

As  to  the  development  of  the  attack,  we  distinguish 
an  acute  form  characterized  by  severe  symptoms :  intense 
agitation  or,  on  the  contrary,  profound  stupor,  inces- 
sant hallucinations,  extreme  confusion  with  clouding 
of  consciousness,  etc. ;  and  a  subacute  form  characterized 
by  symptoms  of  lesser  intensity  and  by  periods  of 
comparative  lucidity  alternating  with  delirious  periods. 

In  some  exceptional  cases  of  ursemic  delirium  of  the 
subacute  form  the  delusions  become  systematized  and 
may  thus  be  misleading  in  the  diagnosis. 

The  mental  symptoms  of  uraemic  delirium  present  no 
pathognomonic  features  and  are  merely  a  manifesta- 
tion of  poisoning  of  the  cerebral  cells.  The  diagnosis 
must  be  made  from  the  accompanying  somatic  symp- 
toms: convulsive  attacks,  cardiovascular  disorders, 
dyspnoea,  oedema,  pupillary  manifestations, — myosis 
and  paresis  of  the  pupils, — diminution  of  the  specific 
gravity  and  of  the  toxicity  of  the  urine,  albuminuria, 
anuria,  oliguria,  or  polyuria. 

Uraemic  delirium  is  often  very  similar  to  delirium 
tremens.  It  seems  that  the  two  affections  may  even 
be  combined.  Brault  ^  is  of  the  opinion  that  uraemia, 
like  traumatism  or  pneumonia,  may  act  as  the  exciting 

'  Brissaud.  De  la  catatonic  brightique.  Sem.  ined.,  1893. — 
Cullerre.  Sur  un  cas  de  folic  urcmiqiie  consecutif  a  un  rctrecissement 
traumatique  de  Vurcthre.     Arch,  de  neurol.,  Vol.  XXVII,  No.  89. 

'  Traite  de  medecine.     Charcot-Bouchard.     Maladies  des  reins. 


484  MANUAL  OF   PSYCHIATRY. 

cause  of  an  attack  of  delirium  tremens.  We  have 
already  seen  how  much  importance  is  attributed  by 
some  authors,  notably  by  Herz,  to  uraemia  as  a  patho- 
genic factor  in  delirium  tremens. 

The  prognosis  depends  upon  the  severity  of  the 
somatic  disturbances. 

The  treatment  is  that  of  uraemia  in  general:  milk 
diet,  blood-letting,   purgatives,   and  diaphoretics. 


CHAPTER  XIX. 

MISCELLANEOUS  GROUPS  (Continued). 
THYROGENIC  PSYCHOSES. 

Destruction  of  the  thyroid  gland  gives  rise  to  a 
pecuHar  autointoxication  which  is  met  with  in  two 
different  cHnical  forms:  myxcedema  and  cretinism;  in 
the  former  the  destruction  of  the  gland  occurs  at  an 
adult  age,  in  the  latter  it  occurs  in  infancy. 

§  1.  Myxcedema. 

The  external  aspect  of  a  myxoedematous  patient  is 
characteristic.  The  puffed  and  expressionless  face 
together  with  the  general  attitude  reflect  both  the 
mental  inertia  and  the  profound  disorder  of  general 
nutrition. 

Psychic  disturbances.  —  These  consist  chiefly  in  symp- 
toms indicating  a  blunting  and  torpor  of  cerebral  activity, 
—  psychic  paralysis ;  there  is  extreme  sluggishness  of 
association  of  ideas  demonstrable  by  simple  clinical 
examination  as  well  as  by  psychometry;  the  attention 
is  difficult  to  obtain  and  to  fix;  there  are  also  retro- 
grade amnesia  by  default  of  reproduction  and  antero- 
grade amnesia  by  default  of  fixation;  permanent  in- 
difference; abouha. 

485 


486  MANUAL  OF   PSYCHIATRY. 

The  indifference  is  occasionally  interrupted  by  tran- 
sient attacks  of  irritability.  Myxoedematous  patients 
are  often  sulky  and  ill-natured. 

Physical  disturbances. — The  sleep  is  diminished,  re- 
placed by  permanent  somnolence,  and  disturbed  by 
nightmares. 

The  reflexes  are  diminished  or  completely  abolished; 
all  movements  are  sluggish,  awkward,  and  clumsy. 

But  the  most  interesting  disorders  are  those  of  the 
integuments  and  of  the  thyroid  gland. 

Integuments.  — The  skin  is  thickened  and  infiltrated; 
its  surface  is  smooth  and  of  a  dull  whiteness.  On 
palpation  it  gives  the  sensation  of  waxy  tissue.  There 
is  no  pitting  on  pressure,  this  being  a  point  of  dis- 
tinction between  myxoedematous  infiltration  and  ana- 
sarca. 

The  features  are  dulled,  the  eyes  sunken,  and  the 
lips  thickened;  the  wrinkles  of  the  forehead  disappear, 
and  the  naso-labial  fold  becomes  effaced.  The  physiog- 
nomy is  immovable  and  stupid.  The  hair  of  the  head, 
eyebrows,  and  beard  is  scant,  discolored,  and  atrophied. 
These  characteristics  are  pathognomonic  of  the  myxoe- 
dematous facies. 

The  hair  over  the  entire  body  is  atrophied.  The 
nails  become  deformed  and  brittle. 

The  mucous  membranes  present  thickening  analo- 
gous to  that  of  the  skin.  They  are  pale,  anaemic,  and 
in  places  cyanotic. 

Thyroid  gland. — On  palpation  one  finds  atrophy  or 
even  complete  disappearance  of  the  gland. 

Sometimes  the  thyroid  gland  is  increased  in  size, 
causing  an  abnormal  prominence  in  front  of  the  neck. 


THYROGENIC    PSYCHOSES.  487 

This  hypertrophy,  true  or  false,  is  generally  transitory, 
and  occurs  chiefly  in  the  earlj^  stages  of  the  disease. 
When  the  swelling  persists  through  the  entire  duration 
of  the  affection,  it  is  usually  the  result  of  a  cystic  degener- 
ation of  the  gland. 

The  visceral  disorders  do  not  present  any  charac- 
teristic features;  they  indicate  general  atony  and 
diminished  vitality  of  the  organism:  small,  compres- 
sible pulse,  sluggish  and  painful  digestion,  and  con- 
stipation. 

The  course  of  myxoedema  is  progressive,  but  inter- 
rupted by  frequent  remissions. 

If  no  appropriate  treatment  is  instituted,  the  stock  of 
ideas  becomes  diminished,  the  psychic  inertia  becomes 
extreme,  and  complete  dementia  is  established;  also 
the  physical  symptoms  become  accentuated  and  death 
supers'enes  either  from  cachexia  or  from  some  compli- 
cation (pulmonary  tuberculosis). 

Treatment. — It  is  possible  to  supply,  to  a  certain 
extent,  the  deficiency  caused  by  atrophy  of  the  thyroid 
gland  by  the  administration  of  the  thyroid  substance  of 
animals  (almost  exclusively  that  of  the  sheep),  either 
in  the  crude  form  or  in  the  form  of  pharmaceutical  prep- 
arations. The  thyroid  substance  may  be  administered 
in  tablets,  pills,  or  capsules  containing  it,  either  in  the 
fresh  state  or  dried  and  reduced  to  a  powder.  The 
capsules  of  Vigier  contain  ten  centigrams  of  the  fresh 
gland;  they  may  be  administered  in  doses  as  high  as 
six  capsules  per  day  without  inconvenience. 

A  glycerine  extract  of  thyroid  gland  is  also  prepared 
and  is  known  by  the  name  of  thyroidine. 

Finally,  Baumann  and  Proos  have  extracted  from  the 


488  MANUAL   OF    PSY(^HIATRY. 

sheep's  thyroid  a  substance,  iodothyrine,  which  seems 
to  be  the  active  principle.  This  substance  is  '^  tritu- 
rated with  sugar  of  milk  in  such  proportions  that  one 
gram  of  the  mixture  represents  one  gram  of  the  fresh 
gland."  ^ 

Thyroid  medication  must  be  employed  with  great 
caution.  Toxic  symj^toms  are  easily  produced :  acceler- 
ation of  the  pulse  and  respiration,  headache,  attacks  of 
vertigo,  and,  in  severe  cases,  a  tendency  to  collapse. 
Therefore  it  is  advisable  to  begin  the  treatment  with 
small  doses,  which  should  be  gradually  increased,  and 
promptly  reduced  or  suspended  entirely  on  the  appear- 
ance of  alarming  symptoms. 

The  mental  and  physical  effects  of  thyrotlierai)y  are 
very  rapid.  In  a  few  days  the  cerebral  torpor  becomes 
less  marked,  the  skin  reassumes  its  normal  aspect,  and 
the  other  myxcrdematous  symptoms  become  abated. 

§  2.  Cretinism. 

Cretinism  may  be  defined  as  an  arrest  of  somatic  and 
I)svchic  development  dependent  generally  upon  a  goitre, 
and  more  rarely  u])on  8im])le  atrophy  of  the  thyroid 
gland. 

The  affection  occurs  endemically  in  mountainous  re- 
gions, such  as  the  Al})s,  the  Rocky  Mountains,  the  high 
plateaus  of  Himalaya,  Black  Forest,  etc.,  and  sporad- 
ically in  most  regions. 

Its  etiology  is  not  well  known.  Numerous  factors  are 
said  to  be  capable  of  causing  it:  atmospheric  humidity; 


'  liriquet.       Yalevr    comparee      des      medications    thijroidiennes. 
Presse  medic,  1902,  Xo.  74. 


THYROGENIC  PSYCHOSES.  489 

certain  geological  compositions  of  the  soil  (cretinism 
occurs  frequently  in  countries  where  the  soil  is  composed 
of  schistose  clay  or  of  streaked  sandstone) ;  poor  quality 
of  the  water,  which  in  the  endemic  sections  is  poorly 
aerated,  deprived  of  iodine,  and  charged  with  calcium 
and  magnesium  salts;  want;  heredity. 

All  these  causes,  the  influence  of  which  should  be 
kept  in  view,  probably  only  prepare  the  soil  for  the 
action  of  some  specific  agent  still  unknown.  Accord- 
ing to  the  opinion  of  Griesinger,  "  endemic  goitre  and 
cretinism  are  specific  diseases  produced  by  a  toxic  cause 
of  miasmatic  nature."  This  attitude  certainly  most 
nearly  corresponds  to  the  modern  medical  consensus 
of  opinion  and  has  at  present  the  greatest  number  of 
adherents.  In  fact  one  cannot  fail  to  note  the  similarity 
which  exists  between  the  etiology  of  endemic  goitre  and 
that  of  other  endemic  diseases  of  parasitic  or,  as  Grie- 
singer says,  miasTnatw  origin,  such  as  malaria. 

The  symptoms  of  cretinism  usually  appear  in  early 
childhood.  Sometimes  the  onset  is  acute,  so  that  the 
destruction  of  the  gland  is  accomplished  in  a  few  days. 
Such  was  the  case  reported  by  Shields,  ^  in  which  an 
acute  thyroiditis  caused  the  destruction  of  the  thyroid 
gland  and  resulted  in  cretinism. 

Much  more  frequently  the  process  is  insidious,  and  it 
is  impossible  to  ascertain  the  exact  date  of  onset. 

The  size  of  the  goitre  is  variable.  The  swelling  may 
be  slight,  scarcely  perceptible,  or  so  enormous  as  to 
completely  disable  the  patient.  Resulting  usually 
from  a  degeneration  of  the  thryoid  gland,  it  becomes 

'  .4.  Case  of  Cretinism  Follovoing  an  Attack  of  Acute  Thyroiditis. 
New  York  Med.  Jour.,  Oct.  1,  1898. 


490  MANUAL  OF   PSYCHIATRY. 

evident  at  about  the  sixth  or  eighth  year  of  age  and 
increases  up  to  the  time  of  puberty  or  even  later. 

Simple  atrophy  of  the  gland  is  much  less  frequent  and 
is  seen  chiefly  in  sporadic  cases. 

Physically  the  cretin  exhibits,  in  addition  to  the 
changes  in  the  thyroid  gland,  the  following  symptoms: 
the  stature  is  below  the  normal;  the  face  is  pale,  puffed, 
or  marked  precociously  with  senile  wrinkles;  the  pilous 
system  is  poorly  developed;  the  mucous  membranes 
are  pale,  anaemic,  and  thickened;  the  teeth  are  abnormal 
in  shape  and  in  implantation  and  subject  to  caries; 
puberty  is  retarded  or  even  absent,  and  the  cretin  may 
remain  infantile  all  his  life. 

Psychically  we  encounter  all  degrees  of  idiocy  and 
imbecility.  It  seems,  however,  that  the  cretin  is  less 
impulsive,  more  manageable,  and  more  capable  of 
emotional  activity  than  the  ordinary  idiot  or  imbecile.^ 

The  brains  of  cretins  present  no  known  specific 
lesions;  asymmetry  and  various  malformations  of  the 
hemispheres  are  frequent. 

The  treatment^  consists  in  thyroid  medication,  the 
results  of  which  are  the  more  perceptible  the  earlier 
it  is  instituted. 

*  Botirneville.     Proyrvs  mi'dical,  1897. 
»  Ibid.,  1890. 


CHAPTER  XX. 

MISCELLANEOUS  GROUPS   {Continued). 

MENTAL  DISORDERS  DUE  TO  ORGANIC  CEREBRAL 
AFFECTIONS. 

All  the  so-called  organic  cerebral  affections, 
whether  diffuse  or  locaUzed,  have  an  influence  upon 
the  psychic  functions. 

The  most  important  among  those  which  have  not 
already  been  considered  are  tumors,  multiple  sclero- 
sis, brain  abscess,  and  central  neuritis. 

Tumors,  when  small  and  of  slow  growth,  may  give 
rise  to  no  mental  symptoms..  In  other  cases  the 
mental  state  presents  certain  peculiarities  which  may 
aid  in  the  diagnosis :  Dupre  and  Devaux  ^  have  found 
that ',' patients  suffering  from  cerebral  tumor  present 
a  peculiar  state  of  mental  depression  and  enfeeble- 
ment,  which  constitutes  their  dominant  psychopathic 
note :  this  state  is  one  of  torpor,  psychic  dullness,  and 
clouding  of  the  intellect,  to  which  may  be  added  mental 
puerilism.''  Properly  speaking  these  cases  present  no 
true  dementia  until  the  affection  has  reached  its  termi- 
nal period.  According  to  the  same  authors ^  ''the  in- 
telligence, though  clouded,  is,  however,  not  destroyed. 
It  responds  to  strong  stimuU,  to  imperious  injunc- 
tions;  it  is  veiled,  but  nevertheless  present,  and  not 

^  Nouvelleiconographie  delaSalpetriere      Tumeur  cerebrale.    1901, 
Nos.  2  and  3,  p.  51. 
2  Loc  cit.,  p.  8, 

491 


492  MANUAL  OF  PSYCHIATRY. 

until  the  last  phases  of  the  development  of  the  affec- 
tion does  it  decline  and  finally  disappear." 

The  diagnosis  of  brain  tumor  is  based  chiefly  on  the 
neurological  symptoms;  these  are  usually  classified  into 
general  symptoms,  common  to  all  tumors  and  resulting 
from  increase  of  intracranial  pressure,  —  severe  and 
persistent  headache,  slow  pulse,  vertigo,  vomiting,  and 
gradual  impairment  of  vision  due  to  optic  neuritis,  — • 
and  focal  symptoms,  varying  with  the  location  of  the 
tumor,  —  Jacksonian  epilepsy,  monoplegia,  hemiplegia, 
aphasia,  apraxia,  hemianopsia,  oculo-motor  paralysis,  etc. 

The  differentiation  between  brain  tumor  and  general 
paresis  may  present  considerable  difficulty,  the  more  so 
in  view  of  the  fact  that  in  the  case  of  tumors  involving 
the  meninges  the  cerebro-spinal  fluid,  as  in  general 
paresis,  may  show  an  increase  of  cellular  elements.  The 
application  of  the  Wassermann  reaction  may  aid  mate- 
rially in  the  diagnosis. 

Multiple  sclerosis  may  be  accompanied  by  a  grad- 
ually progressive  mental  deterioration  simulating  that 
of  general  paresis.  In  such  cases  too  the  application  of 
the  Wassermann  reaction  may  aid  in  the  diagnosis. 

Brain  abscess  occurs  chiefly  as  a  complication  of 
chronic  purulent  otitis  media.  The  symptoms  are  slow 
pulse,  localized  headache,  fever  of  the  asthenic  type, 
often  subnormal  temperature;  mentally  there  are  dull- 
ness, confusion,  restlessness,  and  in  severe  cases  coma. 
The  abscess  is  generally  located  either  in  the  temporal 
lobe  — when  amnesic  aphasia  is  a  prominent  symptom 
if  the  lesion  is  on  the  left  side  —  or  in  the  cerebellar 
hemisphere  — causing  vomiting,  vertigo,  and  staggering 
gait.     The   diagnosis   rests   upon   a   history  of   chronic 


ORGANIC  CEREBRAL  AFFECTIONS.      493 

otitis  media,  the  symptoms  here  enumerated,  and  a  mi- 
croscopical examination  of  the  blood  which  generally 
reveals  leucocytosis;  an  exploratory  operation  may  be 
necessary  and  should  be  done  early  in  every  case  in 
which  this  condition  is  suspected. 

Central  neuritis.  Cases  of  this  highly  interesting 
though  rather  rare  condition  have  been  reported  by 
Wiglesworth,^  Meyer,^  Worcester,^  Turner,^  Cotton  and 
Southard,^  Somers  and  Lambert,^  and  others.  The  first 
systematic  clinical  and  anatomical  study  was  made  by 
Meyer.^ 

Although  clinically  this  condition  is  not  very  well 
defined  and  varies  a  good  deal  in  its  aspect,  the  anatom- 
ical changes  found  post  mortem  are  highly  characteristic 
and  constitute  the  basis  of  its  autonomy. 

These  changes  are  revealed  only  on  microscopic  ex- 
amination and  consist  in  widespread  parenchymatous 
degeneration  of  the  central  nervous  system  unaccom- 
panied   by  any    inflammatory  reaction.      Large   nerve 

^  J.  Wiglesworth.  On  the  Pathology  of  Certain  Cases  of  Melan- 
cholia Attonita,  or  Acute  Dementia.     Journ.  of  Ment.  Sc,  Oct.,  1883. 

^  Adolf  Meyer.  Demonstrations  of  Various  Types  of  Changes  in 
the  Giant  Cells  of  the  Paracentral  Lobules.  Amer.  Journ.  of  Ins., 
Oct.,  1897. 

'  W.  L.  Worcester.  A  Case  of  Landry's  Paralysis.  Journ.  of 
Nerv.  and  Ment.  Dis.,  1897. 

*  John  Turner.  N^ote  on  a  Form  of  Dementia  Associated  ivith  a 
Definite  Change  in  the  Appearance  of  the  Pyramidal  and  Giant-Cells 
of  the  Brain.     Brain,  1899. 

^  H.  A.  Cotton  and  E.  E.  Southard.  A  Case  of  Central  Neuritis 
with  Autopsy.     Trans,  of  the  Amer.  Med.-P.sychol.  Ass'n,  1908. 

^  E.  M.  Somers  and  C.  I.  Lambert.  Central  Neuritis.  State 
Hosp.  Bulletin,  December,  1908. 

"  Adolf  Meyer.  On  Parenchymatous  Systemic  Degenerations 
Mainly  in  the  Central  Nervous  System.     Brain,  1901. 


494  MANUAL  OF  PSYCfllATRY 


c\  .- 


m 


^.-^' 


-f5*' 


^ 


'--  ^v-  - 


m  ■■mr     t  i 


FIG.    15.     NORMAL   BETZ   CELL.      ^After   Adolf    Meyer.) 


FIG.    16.    CELL   FROM   A  CASE   OF  CENTRAL   NEURITIS,    SHOWING   AXONAL 
ALTERATION.      (After   Adolf    Meyer.) 


ORGANIC  CEREBRAL  AFFECTIONS.      495 

cells,  especially  those  in  the  motor  area  of  the  cortex 
in  both  cerebral  hemispheres,  present  the  so-called 
axonal  alteration:  the  cell  body  is  somewhat  swollen; 
the  stainable  substance,  especially  in  the  central 
part  of  the  cell,  is  converted  into  a  diffusely  staining, 
structureless,  or  into  a  finely  powdered,  mass;  the 
nucleus  is  pushed  toward  the  periphery  of  the  cell 
and  may  be  sUghtly  flattened  or  distorted.  Marchi 
preparations  reveal  corresponding  degeneration  of 
fiber  tracts,  particularly  those  connected  with  the 
motor  cortical  areas. 

The  nature  of  central  neuritis  is  not  understood, 
and  but  httle  is  known  of  its  etiology.  Most  cases 
that  have  been  reported  occurred  in  asylum  practice 
either  as  terminal  episodes  in  some  chronic  psychoses 
or  in  connection  with  acute  mental  confusion.  It 
affects  both  sexes,  chiefly  in  the  fifth  and  sixth  dec- 
ades of  fife  or  thereabouts.  In  most  of  the  cases 
no  exciting  cause  is  assigned;  in  a  considerable 
number  the  trouble  is  said  to  have  followed  an  at- 
tack of  influenza,  and  in  three  cases  it  followed  slight 
surgical  operations  done  under  general  ansesthesia. 

Singer  and  Pollock^  found  the  lesions  of  central 
neuritis  in  a  series  of  twelve  cases  of  pellagra  dying 
during  the  acute  or  subsiding  stages  of  the  pellagrous 
attack.  ''Seven  of  them  died  at  a  short  interval 
after  the  skin  lesions  had  subsided,  with  clinical 
symptoms  of  central  neuritis.  In  the  other  five  there 
were  no  symptoms,  such  as  evidence  of  pyramidal 
tract  lesion  (Babinski  reflex,  jactatoid  spasms,  etc.), 

1  Singer  and  Pollock.  The  Histo pathology  of  the  Nervous  System 
in  Pellagra.     Archives  of  Internal  Medicine,  June,  1913. 


496  MANUAL  OF  PSYCHIATRY. 

to  suggest  central  neuritis,  although  diarrhoea  with 
rapid  and  progressive  emaciation  and  weakness 
were  almost  always  present."  This,  of  course,  sug- 
gests the  possibility  of  an  essential  connection  be- 
tween central  neuritis  and  pellagra  which  had  been 
previously  overlooked. 

The  mental  sympto7ns,  given  in  the  order  of  their 
frequency,  are:  depression  with  anxiety  or  sudden 
apprehensiveness ;  restlessness  and  agitation;  per- 
plexity, confusion;  hypochondriacal  or  persecutory 
delusions,  often  of  an  extremely  absurd  character; 
hallucinations.  Refusal  of  food  has  occurred  in 
more  than  half  of  the  cases,  and  suicidal  tendency 
is  almost  as  common. 

Among  the  physical  symptoms  the  most  striking 
are:  stumbling,  falling,  unsteady  gait;  peculiar 
seizures,  —  faintness,  violent  shaking,  rigidity; 
muscular  twitchings,  irregular  jerky  movements, 
jactations;  maladjustment  in  all  movements;  the 
knee-jerks  are  most  frequently  exaggerated,  but  in 
some  cases  they  are  diminished  or  even  absent;  the 
speech  is  apt  to  become  very  indistinct;  toward  the 
last,  dysphagia;  in  some  cases  there  is  little  or  no 
reaction  to  pin-pricks.  The  general  constitutional 
disturbance  is  grave:  there  is  usually  emaciation 
which  may  be  extreme ;  diarrhoea  has  been  observed 
in  nearly  three-fourths  of  the  cases;  a  slight,  irregular 
febrile  reaction  appears,  the  patient  becomes  ex- 
hausted, falls  into  stupor,  and  dies;  in  some  cases 
death  follows  a  sudden  turn  for  the  worse  or  actual 
collapse. 


CHAPTER  XXI, 

MISCELLANEOUS  GROUPS   (Concluded). 
SENILE  DEMENTIA. 

Senile  dementia  may  be  defined  as  a  peculiar 
state  of  intellectual  enfeeblement,  with  or  without 
delusions,  resillting  from  cerebral  lesions  determined 
by  senility. 

Age  is  here,  therefore,  the  great  etiological  factor; 
it  is,  however,  not  the  sole  factor.  Many  individuals 
attain  extreme  old  age  without  presenting  any  ap- 
preciable intellectual  disorders;  others,  on  the  con- 
trary, have  scarcely  passed  over  the  threshold  of 
senility  when  they  are  already  veritable  dements.^ 
The  effects  of  age  are  the  more  powerful  and  the  more 
precocious  the  more  marked  the  predisposition. 
Heredity,  the  intoxications  (alcoholism),  overwork, 
violent  and  painful  emotions,  traumatisms,  etc.,  are 
also  frequently  given  as  causes. 

Statistics  furnish  a  rather  small  proportion  of  con- 
genitally  predisposed  persons  among  senile  dements, 
but  this  is  perhaps  partly  due  to  the  fact  that  it  is 
frequently  impossible  to  obtain  reliable  family  his- 
tories in  such  cases. 

Senile  dementia  is  rare  before  the  age  of  sixty 

'  Russell.  Senility  and  Senile  Dementia.  Amer.  Journ.  of  In- 
sanity, 1902. 

497 


498  MANUAL  OF  PSYCHIATRY. 

years.  Alcoholism  sometimes  brings  about  an  analo- 
gous state  of  intellectual  enfeeblement,  appearing 
towards  fifty  or  fifty-five  years,  which  has  been  desig- 
nated by  the  term  scenium  prcecox.^  Such  cases  are 
exceptional  if  we  exclude  ordinary  alcoholic  dementia. 

The  onset  sometimes  follows  some  strong  emotional 
shock,  financial  troubles,  or  a  somatic  affection. 
Almost  always  it  is  insidious,  marked  simply  by  a 
change  of  disposition  and  slight  disorders  of  memory. 
When  fully  established  the  dementia  presents  the 
following  fundamental  elements: 

(a)  Impairment  of  attention  and  sluggishness  of  as- 
sociation of  ideas,  readily  demonstrable  by  psy- 
chometry,  as  has  been  shown  by  the  experiments  of 
Rauschburg  and  Balint.^  (These  authors  performed 
their  experiments  upon  cases  of  simple  senile  de- 
mentia without  delusions.)  A  curious  fact  observed 
in  these  experiments  is  that  associations  of  ideas  were 


^  Cases  essentially  of  premature  senility  have  been  dascribed 
under  the  name  of  Alzheimer's  disease.  See  Alzheimer.  Ueber 
eigenartige  krankhdtsfdlle  des  spdteren  Alters.  Zeitschr.  f.  d.  gesamte 
Neurol,  u.  Psychiatrie,  Vol.  IV,  p.  365.  —  Perusini.  Ueber  klinisch 
und  hislologisch  eigenartige  psychische  Erkrankungen  des  spdteren 
Lebensallers.  NLssl's  Arbeiten,  Vol.  II,  p.  297.  —  S.  C.  Fuller.  A 
Study  of  the  Miliary  Plaques  Found  in  Brains  of  the  Aged.  Amer. 
Journ.  of  Ins.,  Oct.;  1911.  —  S.  C.  Fuller.  Alzheimer's  Disease 
{Senium  Prcvcox):  The  Report  of  a  Case  and  Review  of  all  Published 
Cases.  Journ.  of  Nerv.  and  Ment.  Dis.,  Vol.  XXXIX,  1912.— 
S.  C.  Fuller  and  II.  I.  Kloi)p.  Further  Observations  on  Alzheimer's 
Disease.  Amer.  Journ.  of  Ins.,  July,  1912.  —  W.  J.  Tiffany.  The 
Occurrence  of  Miliary  Plaques  in  Senile  Brains.  Amer.  Journ.  of 
Ins.,  Jan.,  1914. 

2  Ueber  qualitative  und  quantitative,  etc.  Allgem.  Zeitsch.  fiir 
Peychiat.,  1900. 


SENILE  DEMENTIA.  499 

almost  always  determined  by  the  sense  of  the  words, 
and  rarely  by  similarities  of  sound  or  by  rhymes. 
It  will  be  remembered  that  associations  by  simi- 
larities of  sound  are  the  result  of  automatic  psychic 
activity;  it  seems,  therefore,  that  mental  automa- 
tism, instead  of  being  exalted,  as  it  is  in  certain 
psychoses  (mania),  is  like  voluntary  psychic  activity, 
diminished,  at  least  in  simple  senile  dementia  with- 
out delusions. 

(b)  Inaccurate  and  incomplete  perception  of  the  ex- 
ternal world,  the  consequence  of  which  is  the  pro- 
duction of  numerous  illusions  and  of  disorientation 
of  place. 

(c)  Disorders  of  memory,  comprising : 

(I)  Amnesia  of  fixation  (anterograde  amnesia), 
which  entails  disorientation  of  time; 

(II)  Amnesia  of  conservation  (retrograde  amnesia), 
which  is  progressive  and  which  follows  almost  per- 
fectly the  law  of  retrogression; 

(III)  Illusions  and  hallucinations  of  memory,  which 
form  the  basis  of  pseudo-reminiscences,  often  absurd 
or  puerile  in  character  and  varying  from  one  instant 
to  another. 

(d)  Impoverishment  of  the  stock  of  ideas:  old  im- 
pressions disappear  and  are  not  replaced  by  new 
ones.  This  is  the  cause  of  the  tiresome  repetitions 
in  the  discourses  of  old  dotards. 

(e)  Loss  of  judgment:  the  patient  does  not  accept 
new  points  of  view.  He  mourns  for  the  good  old 
times  and  shows  a  profound  contempt  for  new  ideas 
which  he  is  incapable  of  assimilating.  This  con- 
tempt for  the  present  is  met  with  in  many  old  people, 


500  MANUAL  OF  PSYCHIATRY. 

but  not  in  combination  with  any  appreciable  mental 
deterioration. 

The  senile  dement  has  no  realization  of  his  own 
condition.  Often  he  boasts  of  his  endurance,  his 
strong  will,  his  lucid  mind,  and  declares  that  he  is  in 
no  need  of  assistance  from  any  one  and  that  he  is 
quite  well  able  to  manage  his  own  affairs. 

(/)  Diminution  of  affectivity,  morbid  irritability: 
hence  the  indifference  of  senile  dements  for  their  rel- 
atives and  their  interests,  their  unprovoked  out- 
bursts of  anger,  their  tjrrannical  tendencies,  and  their 
occasional  emotionalism. 

{g)  Automatic  character  of  the  reactions:  from  this 
point  of  view  senile  dements  may  be  divided  into 
two  classes:   the  turbulent  and  the  apathetic. 

The  turbulent  are  always  moving,  intrude  every- 
where, give  unreasonable  or  contradictory  orders,  get 
up  during  the  night  and  wander  about  the  house  with 
a  candle  in  their  hand  at  the  risk  of  starting  a  fire. 
Their  mood  is  either  depressed  or  elated  and  hypo- 
maniacal.  Sexual  excitement,  most  often  purely 
psychic,  is  quite  likely  to  be  associated  with  this 
state,  and,  together  with  the  intellectual  enfeeble- 
ment,  leads  the  patient  to  dangerous  acts:  attempts 
at  rape,  indecent  exposures,  etc.^ 

The  apathetic  senile  dements  have  an  indifferent, 
stupid  aspect.  The  patient's  mouth,  half  open,  al- 
lows the  saliva  to  dribble;  he  remains  motionless 
upon  the  chair  where  he  has  been  placed ;  he  is  docile, 

*  By  tJie  term  exhihitionmn  lias  been  designated  a  morbid  tend- 
ency, which  certain  psychopaths  have,  to  exhibit  pubUcly  their 
genital  organs. 


SENILE  DEMENTIA.  501 

obedient,  and  very  suggestible.  When  in  the  hands 
of  unscrupulous  persons,  he  allows  himself  without 
protestation  to  be  swindled  and  maltreated,  and  un- 
consciously yields  to  inveiglements  for  imprudent 
disposal  of  his  property. 

In  advanced  stages  of  the  disease  the  turbulent  as 
well  as  the  apathetic  senile  dements  frequently  be- 
come filthy,  often  soihng  and  wetting  themselves. 

Sleep  is  diminished  and  often  even  absent  in  the 
excited  forms.  On  the  other  hand,  constant  somno- 
lence is  frequent  in  the  apathetic  cases. 

Together  with  the  dementia  there  are  the  regular 
signs  of  seniUty.  The  skin  is  wrinkled  and  dis- 
colored; the  hairy  system  is  undergoing  atrophy; 
the  patellar  reflexes  are  sometimes  abolished,  but 
more  frequently  exaggerated;  the  pupils  are  slightly 
myotic  and  paretic:  arcus  senilis  is  well  marked; 
there  is  hyposesthesia  of  all  the  senses;  all  move- 
ments are  awkward  and  uncertain;  there  is  diminu- 
tion of  the  muscular  power;  senile  tremors  affect 
the  entire  body  and  especially  the  head,  consisting 
of  coarse  oscillations. 

The  cardio-vascular  symptoms  are  of  great  im- 
portance. 

The  frequent  association  of  senile  dementia  with 
arteriosclerosis  has  already  been  mentioned.  Vascu- 
lar disease  is,  however,  not  invariably  present  and  is 
often  but  slight:  senile  atrophy  is  a  process  essen- 
tially independent  of  arteriosclerosis. 

The  appetite  is  diminished,  or,  on  the  contrary,  it 
may  be  exaggerated  to  a  degree  constituting  voracity. 
In  the  latter  case  the  patient's  diet  should  be  care- 


502  MANUAL  OF  PSYCHIATRY. 

fully  regulated  to  prevent   grave  gastro-intestinal 
disturbances. 

Delusional  forms.  —  The  delusions  bear  the  stamp 
of  dementia:  they  are  absurd,  changeable,  and  pre- 
sent little  or  no  tendency  to  systematization.  They 
may  be  of  the  following  varieties: 

(a)  Ideas  of  persecution,  which  in  their  mildest 
form  manifest  themselves  by  mere  suspiciousness 
such  as  is  always  common  in  old  persons.  Their 
form  is  varied:  ideas  of  poisoning,  of  theft,  of 
jealousy,  fear  of  being  killed,  etc. 

Persecutory  ideas  are  more  likely  to  become  system- 
atized than  any  others,  though  the  systematization  is 
very  imperfect,  and  more  Ukely  to  be  accompanied  by 
hallucinations,  chiefly  of  hearing  and  of  vision. 
Sometimes  these  delusions  appear  long  before  any 
evidences  of  dementia,  constituting  the  presenile 
paranoid  state  {prceseniler  Beeintrdchtigungswahn)  of 
Kraepelin. 

(6)  Melancholy  ideas  of  all  possible  types :  ideas  of 
self-accusation,  of  ruin,  etc.  Ideas  of  negation  are 
very  frequent. 

(c)  Ideas  of  grandeur,  which  are  at  times  absurd, 
resembUng  those  of  general  paretics. 

The  delusions  are  associated  with  a  corresponding 
state  of  the  emotions  and  of  the  reactions.  Three 
principal  forms  of  delusional  senile  dementia  may  be 
distinguished : 

(1)  Persecutory  form:  ideas  of  persecution;  re- 
actions of  self-defense  which  may  at  times  be  violent. 

(2)  Melancholic  form:  melancholy  ideas,  psychic 
pain,  depression,  anxiety,  suicidal  ideas. 


SENILE  DEMENTIA.  503 

(3)  Maniacal  form:  euphoria,  ideas  of  grandeur, 
variable  moods,  impulsive  reactions,  sometimes  flight 
of  ideas,  erotic  tendencies,  etc. 

Senile  dementia  is  sometimes  marked  by  acute 
attacks  characterized  by  complete  disorientation  and 
hallucinations,  closely  resembling  certain  phases  of 
general  paresis,  but  especially  delirium  tremens  {senile 
delirium).  These  attacks,  usually  very  brief,  termi- 
nate either  in  death  or  in  a  return  to  the  previous 
condition.  They  may  occur  in  old  persons  independ- 
ently of  any  intellectual  enfeeblement  (Wernicke). 

The  principal  complications  of  senile  dementia  are: 

Apoplectic  and  sometimes  epileptic  seizures  (senile 
epilepsy),  hemiplegia,  aphasic  phenomena,  etc. 

Alcoholism  in  the  form  of  episodic  accidents  (de- 
lirium tremens)  or  of  alcoholic  dementia  may  be 
associated  with  senile  dementia. 

The  prognosis  is  fatal.  The  affection  always  fol- 
lows a  progressive  course.  Remissions  are  very  rare 
and  never  complete.  Death  usually  supervenes  at 
the  end  of  from  three  to  five  years,  as  a  result  of  senile 
cachexia,  of  some  intercurrent  disease  (pneumonia), 
or  of  apoplexy. 

Not  all  psychoses  occurring  at  an  advanced  age  are 
senile  dementia.  Old  men  present  attacks  of  manic 
depressive  insanity,  paranoia,  and  other  psychoses 
which  differ  in  no  way  from  those  observed  in  younger 
people.^ 

^  Thivet.  Contribution  a  Vetude  de  la  folie  chez  les  vieillards. 
These  de  Paris,  1889.  —  Regis.  Psychoses  de  la  vieillesse.  Ann. 
med.  psych.,  March-April,  1897.  —  Ritti.  Les  psychoses  de  la 
vieillesse.     Congres  des  medecins  ahenistes  et  neurologistes,  1896. 


504  MANUAL  OF  PSYCHIATRY. 

The  diagnosis  is  based  upon  the  pathognomic 
features  of  the  dementia. 

Involutional  melancholia  and  manic  depressive  in- 
sanity may  be  distinguished  by  the  absence  of  intel- 
lectual enfeeblement,  by  the  preservation  of  lucidity, 
and  by  the  intensity  of  the  affective  phenomena  — 
psychic  pain  or  euphoria. 

General  paresis  may  be  differentiated  by  the  more 
rapid  development  of  dementia  and  by  its  special 
physical  signs. 

Alcoholic  dementia  shows  the  physical  signs  of 
chronic  alcoholism:  muscular  pain,  tremors,  gastric 
disorders,  *  etc.  Senile  dementia  and  alcoholic  de- 
mentia may  exist  together. 

The  anatomical  lesions  arise  from  a  process  of  wear 
and  atrophy:  atheroma  of  the  cerebral  arteries, 
thickening  of  the  meninges,  diminution  of  the  weight 
of  the  brain,  which  may  sometimes  fall  below  1000 
grams;  thinning  of  the  cortex;  numerous  miliary 
plaques;  diminution  of  the  number  of  nerve-cells, 
chromatolysis,  pigmentary  degeneration,  atrophy; 
disappearance  of  a  large  number  of  tangential  fibers. 

The  treatment,  purely  symptomatic,  consists  chiefly 
in  hygienic  measures.  Commitment  is  but  seldom 
necessary.  The  majority  of  cases  are  best  treated 
in  special  asylums  for  the  aged  or  in  private  homes. 


INDEX   OF  AUTHORS. 


Alzheimer,  A.,  285,  421,  447,  495.  Bouchard,  Ch.,  394,  463,  483. 

Amsden,  G.  S.,  98,  434,  Bourneville,  M.,  225,  490. 

Angiolella,  D.,  424.  Bramwell,  Milne,  63. 

Anglade,  J.,  421.  Brault,  J.,  483. 

Antheaume,  A.,  376.  Bridges,  J.  W.,  151. 

Arnaud,  57,  69,  347,  403,  412.  Brill,  A.  A.,  10,  175. 

Aschaffenburg,  G.,  8,  155,  201,  Briquet,  488. 

461.  Brissaud,  E.,  80,  394,  463,  483. 

Browning,  C.  H.,  426. 

Babinski,  J.,  371,  408,  416,  438,  Busch,  Max,  34. 

495. 

Baer,  A.,  203.  Calmeil,  J.  L.  F.,  393 

BaiUarger,  J.,  64,  168,  393.  Capeletti,  245. 

Baillet,  401.  Capgras,  J.,  324. 

BaUnt,  R.,  498.  Capps,  403. 

Ball,  C.  R.,  24,  162.  Carrier,  349. 

BaUet,  G.,   287,  394,  421,  463,  Casamajor,  L.,  227. 

468.  Castin,  P.,  69. 

Baumann,  W.,  487.  Chambard,  471,  473,  476. 

Bayle,  393.  Charcot,  J.  M.,  394,  425,  446, 
Beaunis,  H.,  42.  463,  471,  483. 

Bechterew,  W.  v.,  38.  Chaslin,  P.,  462. 

Beers,  C.  W.,  177.  Chenais,  253. 

Bentley,  479.  Christian,  405. 

Bergonie,  I.,  412.  Clerambault,  Gatian  de,  410. 

Bernard,  Claude,  77.  Cololian,  44. 

Besson,  A.,  236.  Cotard,  J.,  69,  267,  329. 

Binet,  A.,  109,  132,  149,  151,  155,  Cotton,  H.  A.,  434,  493. 

197.  Coulon,  394. 

Binswanger,  O.,  444,  449,  468.  Cullerre,  A.,  470,  483. 
Bleuler,  E.,  356. 

Bloch,  A.,  401.  Dagonet,  H.,  405. 

Bonnat,  412.  Darwin,  Charles,  77. 

Bordet,  J.,  116,  117.  Davenport,  C.  B.,  3,  4,  95,  360, 
Bordoni-Uffreduzzi,  77.  362. 

505 


506 


INDEX  OF  AUTHORS. 


Debove,  471. 

D6jerine,  J.,  425. 

Delarras,  291. 

Delasiauve,  462. 

Delaye,  393. 

Delbruck,  A.,  56. 

De  Quincey,  Thos.,  474. 

Desvaux,  458. 

Devaux,  491. 

Dide,  M.,  253. 

Dreyfus,  G.  L.,  325,  326,  332. 

Dubois,  Paul,  174,  175. 

Dumas,  G.,  76,  77,  78,  79,  82, 

296. 
Dunlap,  C.  B.,  426. 
Dupro,  E.,  92,  416,  491. 

Eastman,  F.  C,  158. 
Elderton,  Ethel  M.,  226. 
Ellis,  A.  W.  M.,  434. 
Erlenmeyer,  477. 
Esmarch,  425. 
Esquirol,  J.  E.  D.,  24. 
Exner,  S.,  422. 

Fagan,  J.  O.,  208. 

Falret,  J.,  270,  278,  393. 

Farnarier,  33,  162. 

Fauro,  M.,  468. 

Fore,  Ch.,  234,  235,  236,  237,  238, 

363,  373. 
Ferrari,  M.,  168. 
Fischer,  426. 
Fiske,  C.  X.,  207. 
Fournier,  A.,  195,  207,  426. 
Franz,  S.  I.,  158. 
Freud,  S.,  175,  176,  347,  352. 
Fuchs,  A.,  112,  113,  114. 
Fuhrmann,  M.,  101. 
Fuller,  S.  C.,  498. 
Fursac,    J.     Rogues     de,     107, 

394. 


Gamier,  C,  92,  365. 

Gates,  M.  F.,  207. 

Gengou,  O.,  116,  117. 

Georget,  462. 

Goddard,  H.  H.,  3,  132,  135,  150, 

215. 
Gowers,  W.  R.,  424,  444. 
Gray,  H.,  446. 
Grelliere,  411. 
Griesinger,  W.,   1,  24,  81,   162, 

174,  325,  489. 
Guislain,  162. 

Hamilton,  A.  S.,  361. 

Hardwick,  Rose,  S.,  151. 

Harrison,  L.  W.,  207. 

Haslam,  J.,  393. 

Hayem,  470. 

Hecker,  246. 

Heilbronner,  K.,  66,  237,  242. 

Hellsten,  7. 

Heron,  D.,  194. 

Herter,  C.  A.,  244. 

Herxlieimer,  K.,  433. 

Herz,  M.,  383,  385,  484. 

Hoch,  August,  10,  98,  284,  285, 

315. 
Hoffding,  90. 
Horsley,  V.,  443. 
Huntington,  G.,  223,  359,  360, 

362. 

Jacob,  345. 

Jacquin,  470. 

Janet,  P.,  60,  334,  347. 

Jelliffe,  S.  E.,  174,  227. 

Jcssen,  425. 

Joffroy,  A.,  35,  46,  106,  107,  376, 

383,  411,  416,  425,  478. 
Jones,  Ernest,  131,  175,  420. 
Jouet,  476. 
Jung,  C.  G.,  10,  155,  175,  176. 


INDEX  OF  AUTHORS. 


507 


Kahlbaum,  34,  246. 

Kaplan,  D.  M.,  115,  121,  128, 
420,  441. 

Kent,  Grace  H.,  155,  156,  157. 

K6raval,  P.,  63. 

Kirby,  G.  H.,  12. 

Kirn,  34. 

Klippel,  M.,  373,  382,  385,  394, 
403,  412,  424,  458. 

Klopp,  H.  I.,  498. 

Kohn,  321. 

Koppen,  M.,  56,  456. 

Korsakoff,  388. 

Koster,  W.,  107. 

Kraepelin,  E.,  8,  81,  89,  174,  185, 
201,  223,  246,  247,  252,  270, 
277,  279,  281,  293,  310,  314, 
315,  316,  318,  320,  324,  327, 
373,  394,  426,  432,  452,  461, 
469,  502. 

Krafft-Ebing,  R.  v.,  242,  342, 
345,  405,  425,  431. 

Krishaber,  42. 

Kromayer,  433. 

Kurz,  E.,  8,  201. 

Kutznitzki,  E.,  433. 

Lambert,      C.      I.,      426,     444, 

493. 
Lange,  C.,  77. 
Lange,  Carl,  128,  419. 
Laquer,  B.,  203. 
Lasegue,  377,  393. 
Lavoit,  110. 
Legay,  34. 
Leroy,  287. 

Levinstein,  O.,  476,  477. 
Liepmann,  H.,  35,  380. 
Londe,  P.,  347. 
Lopez,  458. 
Liickerath,  388. 
Lunier,  393. 


Magnan,  V.,  162,  168,  236,  241, 

270,  278,  287,  291,  345,  349, 

393,  394,  399,  405. 
Mahaim,  422,  423. 
Mairet,  A.,  394. 
Mann,  128,  420,  441. 
Marchi,  495. 
Mariani,  C.  E.,  35. 
Marie,  P.,  408. 
Marinesco,  G.,  367. 
Marshall,  C.  F.,  195,  207.. 
Martin,  342. 
Masselon,  247,  251. 
Mayer,  M.,  7,  201. 
McClelland,  128. 
McKenzie,  I.,  426 
Mendel,  E.,  393. 
Mercklin,  164. 
Merson,  J.,  243. 
Meyer,  Adolf,  10,  151,  281,  282, 

284,  454,  456,  493,  494. 
Meynert,  Th.,  45. 
Mignot,  R.,  401. 
Minet,  J.,  110. 
Moebius,  P.  J.,  426. 
Moeli,  241,  242. 
Moll,  Albert,  343. 
Montyel,     Marandon     de,     65, 

408. 
Moore,  Anne,  218. 
Moore,  J.,  131,  394,  427,  428. 
Morselli,  50,  77. 
Mott,  F.  W.,  439. 
Muller,  Jean,  21,  26,  27,  45. 
Muralt,  v.,  280. 
Murphy,  J.  K.,  207,  439. 

Nageotte,  I.,  424. 
Neisser,  A.,  433. 
Nissl,  422,  423,  468,  498. 
Noguchi,  H.,  115,  122,  131,  420, 
426,  427,  428. 


508 


INDEX  OF  AUTHORS. 


Ogilvie,  H.  S.,  434. 
Ormea,  A.  d',  245. 
Orr,  Florence  I.,  3,  6. 
Orton,  S.  T.,  285. 

Pal,  422. 
Parchappe,  393. 
Pearson,  K.,  226. 
Perusini,  G.,  498. 
Peterson,  F.,  10,  175. 
Petri,  118,  119. 
Pfister,  169. 
Pichon,  472,  473,  476. 
Pick,  66,  69. 
Pierracini,  43. 
Pierret,  412. 
Pilcz,  A.,  252. 
Pitres,  A.,  347. 
Plant,  F.,  227,  426. 
Pochon,  162. 
PoUock,  H.  M.,  18. 
Power,  D'Arcy,  207,  439. 
Proos,  487. 

Rauschburg,  P.,  498. 

R6gis,  E.,  242,  347,  351,  503. 

Reiss,  E.,  315. 

Revington,  G.,  30. 

Ribot,  Th.,  54,  57,  58,  91,  347. 

Richet,  245. 

Ritti,  A.,  405,  503. 

Robertson,  A.,  402,  416,  438. 

Rosanoff,  A.  J.,  3,  6,  10,  16,  20, 
115,  131,  155,  156,  157,  158, 
185,  191,  200,  215,  243,  285, 
286,  426. 

RosanofT,  Isabel  R.,  157. 

Rasenthal,  112,  113,  114. 

RO.S.S,  G.  W.,  131,  420. 

Roubinovvitch,  J.,  287,  347. 

Riidin,  E.,  34,  364. 

Rush,  58. 


Russell,  Wm.  L.,  497 
Ryon,  W.  G.,  362. 

Sadras,  393. 

Samt,  237. 

Sander,  73,  288. 

Saulle,    Legrand   du,    235,    237, 

417. 
Saury,  H.,  480. 
Schneider,  L.,  7,  201 
Schule,  79. 
Schultze,  237. 
Schwartz,  242. 
Scglas,  J.,  36,  43,  44,  65,  69,  71, 

107,  287,  329,  348,  462,  463. 
Serieux,  P.,   45,    162,    163,  251, 

376,  394. 
Serveaux,  79,  376,  403. 
Shields,  489. 
Siebert,  46. 
Simon,  Th.,   109,   132,  149,  151, 

155. 
Singer,  H.  D.,  495. 
Sioli,  285. 
Smith,  A.,  8,  201. 
Snydacker,  E.  F.,  430. 
Sollier,  P.,   227,   228,   230,  339, 

478. 
Somers,  E.  M.,  493. 
Sommer,  R.,  60,  101,  235. 
Southard,  E.  E.,  285,  493. 
SpiethofT,  433. 
Stoddart,  W.  H.  B.,  258. 
Strieker,  43. 
Swalm,  128,  420,  441. 
Swift,  H.  F.,  434. 

Tambourini,  A.,  45. 
Thivet,  503. 
Thoma,  112. 
Tiffany,  W.  J.,  498. 
Toulouse,  E.,  245. 


INDEX  OF  AUTHORS. 


609 


Tourette,  Gilles  de  la,  349. 
Trenel,  M.,  69. 
Treves,  M.,  410. 
Tschisch,  W.,  257. 
Tuczek,  422. 
Turner,  J.,  493. 

Vallon,   C,   44,   242,   344,   349, 

408. 
Viallon,  167. 
Vigier,  487. 
Vignaud,  393. 
Vires,  394. 
Voisin,  A.,  235,  393. 

Wardner,  D.  M.,  434. 
Wassermann,  A.,  115,  117,  121, 

208,     419,     425,     433,     451, 

492. 
Weeks,  D.  F.,  3. 


Weigert,  C,  422. 

Wells,  F.  L.,  158. 

Wernicke,  C,  27,  36,  37,  39,  46, 
47,  63,  65,  89,  90,  296,  297, 
377,  379,  383,  405,  503. 

Westphal,  A.,  252,  347. 

Weygandt,  W.,  293. 

Whipple,  G.  M.,  132,  158. 

White,  Wm.  A.,  174,  211. 

Wiglesworth,  J.,  493. 

Willis,  Th.,  444,  446. 

Winslow,  F.,  57,  230. 

Wiseman,  J.  I.,  115,  131,  426. 

Wizel,  162. 

Woodworth,  R.  S.,  158. 

Worcester,  W.  L.,  493. 

Yerkes,  R.  M.,  151. 
Ziehen,  Th.,  318. 


INDEX  OF   SUBJECTS. 


Abortion,  10. 

Aboulia,  77,  86,  306,  336,  462, 

475,  485. 
Abscess  of  the  brain,  492. 
Absinthe,  371. 
Abstinence,  201,  376. 
Acute  delirium,  467. 
Acute  hallucinosis,  385. 
Affectivity,  28,  74,  249,  295,  306, 
335,  397,  500. 

diminution  of,  74. 

disorders  of,  74. 

exaggeration  of,  75. 
After-care,  179. 

Age,  13,  270,  279,  315,  431,  497. 
Agitation,  80. 
Agoraphobia,  352. 
Akoasms,  36. 

Alcohol,  7,  9,  96,  98,  175,  193, 

194,  199,  201,  223,  225,  244, 

274,  321,  349,  363,  368,  430, 

456,  498. 

Alcoholic  delusional  states,  387. 

Alcohohsm,  acute,  363. 

forms,  365. 

pathological  anatomy,  366. 

treatment,  367. 
Alcoholism,  chronic,  368,  430. 

diagnosis,  372. 

episodic  accidents,  377. 

etiology,  193,  373. 

pathological  anatomy,  372. 

physical  symptoms,  370. 

prognosis,  372. 

prophylaxis,  201. 


psychic  symptoms,  368. 

treatment,  376. 
Alcoholism,  parental,  225. 
Alzheimer's  disease,  498. 
Amboceptor,  116. 
Ammonium  sulphate  test,   131, 

420. 
Amnesia,  51,  238,  248,  335,  368, 
388,  396,  475,  485,  499. 

anterograde,  51,  248,  368,  389, 
396,  485. 

course  of,  53. 

general,  55. 

law  of,  53. 

of  conservation,  52,  499. 

of  fixation,  51,  499. 

of  reproduction,  51,  53,  335, 
425. 

partial,  54. 

progressive,  53. 

retrograde,  51,  248,  368,  380, 
396,  485. 

retrogressive,  53. 

stationary,  53. 
Anamnesis,  see  History  taking. 
Anger,  82,  234,  296,  369, 394, 500. 
Antigen,  117. 
Anxiety,  79,  238,  347. 
Aphasia,  55,  151. 
Apoplectiform    seizures  Ln   gen- 
eral paresis,  413. 
Arithmomania,  349. 
Arrests  of  development,  225 

compUcations,  231. 

diagnosis,  233. 


511 


512 


INDEX  OF  SUBJECTS. 


Arrests  of  early  manifestations, 
227. 
etiology,  225. 
prognosis,  233. 
symptoms,  228. 
treatment,  233. 
Arterio-capillary  fibrosis,  447. 
Arteriosclerosis,  444. 
Association  of  ideas,  58,  249,  294, 
305,  318,  325,  334,  364,  397, 
462,  475,  485,  498. 
automatic,  59. 
disorders  of,  59. 
voluntary,  59. 
Association  tests,  155. 
Atavistic  heredity,  2,  360. 
Atrophy  of  the  brain,  285,  362, 

421,  504. 
Attention,  25,  58,  228,  248,  294, 
317,  334,  397,  462,  475,  485, 
498. 
abnormal  mobility  of,  58. 
dehberatc,  58. 
disorders  of,  58. 
paralysis  of,  58. 
spontaneous,  58. 
voluntary,  58. 
Auricle,  deformities  of,  342. 
Autochthonous  ideas,  63. 
Autointoxication,  281,  384,  469, 

482. 
Automatic    reactions,    86,    250, 

257,  336,  465,  500. 
Automatism,  epileptic,  237. 
mental,    255,    317,    334,    347, 
364,  465. 

Bacteriolytic  system,  116. 
Baths,  163. 
Bed-sores,  411. 

prevention  and  treatment  of, 
434. 


Bestiality,  345. 
Binet-Simon  tests,  131. 
Bordet-Gengou    phenomenon, 

117. 
Brachycephaly,  341. 
Brain   atrophy,    285,    362,    421, 

504. 
Bright's  disease,  373,  383,  448. 
Bromides,  in  excitement,  165. 

in  epilepsy,  244. 

in  general  paresis,  436. 

in  manic-depressive  insanity, 
321. 
Broncho-pneumonia,  435. 

prevention  of,  435. 
Business  troubles,  11. 
Butyric  acid  test,  131,  414. 

Cachexia,  in  general  paresis,  418. 

in  morphinism,  477. 

senile,  503. 
Catatonia,  255. 

Catatonic  excitement,  255,  277. 
Catatonic  stupor,  257,  277. 
Causes,  1. 

contributing,  1,  9,  99,  192. 

essential,  1,  2,  191. 

exciting,  11,  181. 

incidental,  1,  9,  99,  192. 

physical,  10. 

psychic,  10. 
Cell  count,  112. 
Central  neuritis,  493. 
Cerebral  arteriosclerosis,  444. 
Cerebral  hemorrhage,  447. 
Cerebral  softening,  447. 
Cerebral  syphilis,  437. 

diagnosis,  440. 

diffuse  meningitic  type,  438. 

endarteritic  type,  440. 

gummatous  type,  440. 

prognosis,  442. 


INDEX  OF  SUBJECTS. 


513 


Cerebral    syphilis,     symptoms, 

438. 
treatment,  443. 
Cerebral  tumors,  491. 
Cerebro-spinal  fluid,  110. 
Certificate  of  lunacy,  160. 
Chemical  tests,  128. 
Childbirth,  10. 
Chloral,  164,  436. 
Chloralose,  166. 
Cholera,  469. 

Chorea,  Huntington's,  97,  359. 
Circular  insanity,  314. 
Circulation,  changes  of,  in  anger, 

82. 
in  depression,  78. 
in  euphoria,  84. 
Circulation,  in  involutional  mel- 
ancholia, 327. 
in  manic  depressive  insanity, 

298,  307. 
Classification,  223. 
Claustrophobia,  352. 
Clouding   of   consciousness,    47, 

238,  300,  303,  365,  397,  460, 

462,  482. 
Cocaine  delirium,  480. 
Cocainomania,  479. 
Coenesthesia,  90. 
Cold  packs,  163. 
Collateral  heredity,  2. 
Colloidal  gold  test,  128,  419. 
Commitment,  159,  210,  358. 
Complement,  116. 
Consciousness,  47,  377,  397,  460, 

462. 
cloudmg  of,  47,  238,  300,  303, 

365,  397,  460,  462,  482. 
exaggeration  of,  47,  50. 
loss  of,  47. 
Constitutional  make-up,  97,  279, 

284,  315. 


Constitutional    psychopaths, 

339. 
Convergent  heredity,  360. 
Convulsions  in  general  paresis, 

413,  436. 
Coprolalia,  349. 
Cranial  deformities,  341. 
Cretinism,  488. 
Crime    and    feeble-mindedness, 

215. 
Crime  and  insanity,  216. 
Criminal  responsibiUty,  213. 

Dangerous  patients,  30,  160. 
Death  of  relatives,  as  a  cause  of 

insanity,  11. 
Degeneration,  physical  stigmata 

of,  341. 
Delire     chronique    a    Evolution 

systematique,  270. 
Delire  du  toucher,  351, 
Delirium,  acute,  467. 

epileptic,  237. 

febrile,  11,  458. 

hallucinatory,  33. 

infectious,  458,  461. 

senile,  503.  • 

traumatic,  455. 

ursemic,  482. 
Delirium  tremens,  241,  274,  377, 
389,  483,  503. 

complications,  381. 

diagnosis,  241,  274,  381. 

pathogenesis,  383. 

pathological  anatomy,  382. 

physical  symptoms,  379. 

prodromata,  377. 

prognosis,  381. 

psychic  symptoms,  377. 

treatment,  384. 
Delusional    interpretations,    66, 
271,  287,  329,  480. 


514 


INDEX  OF  SUBJECTS. 


Delusions,  66,  81,  241,  263,  272, 
277,  289,  299,  308,  319,  329, 
336,  366,  369,  385,  388,  404, 
460,  465,  481,  482,  502. 
Dcmcutiu,  ix,  273,  332. 

alcoholic,  370. 

epileptic,  235. 

senile,  497. 

traumatic,  457. 
Dementia  pnecox,  7,  10,  14,  223, 
246,    292,    337,    372,     387, 
419. 

catatonic  form,  255,  277. 

common  symptoms,  247. 

delusional  forms,  263,  278. 

diagnosis,  274. 

etiology,  279. 

pathological  anatomy,  285. 

prognosis,  275. 

simple  form,  253,  277. 

somatic  disorders  in,  251. 

theories  of,  280. 

treatment,  286. 
Dentition,  anomalies  of,  341. 
Deportation     of    insane    immi- 
grants, 209. 
D(?pression,  active,  76. 

delusional,  308. 

passive,  76. 

recurrent,  313. 

simple,  305. 

stuporous,  309. 
Determiners,  germ-plasmic,  3. 
Diet  in  epilepsy,  243. 
Dipsomania,  349. 
Discharge  of  patients,  179. 
Disorientation,  47,  55,  238,  303, 
377,    390,    397,    448,     482, 
499. 
Dolichocephjily,  341. 
Domestic  troubles,  11. 
Dominant  characters,  3,  860. 


Doubting  mania,  351,  352. 
Douche,  163. 
Dream  delirium,  66,  460. 
Dreams,  in  chronic  alcoholism, 

370. 
Drunkenness,  comatose,  365. 

common,  365. 

convulsive,  366. 

delusional,  366. 

maniacal,  365. 

pathological,  363. 

treatment  of,  367. 
Duplex  inheritance,  4. 

Echo  of  thought,  272. 
Echolalia,  87,  259. 
Echopraxia,  87,  259. 
Ecstasy,  83. 
Education,  17.  . 
Emotions,  see  Affectivity. 
Environment,  rural,  15,  432. 

urban,  15,  432. 
Ependymal    granulations,    421, 

423. 
Epilepsy,  7,  10,  231,  234. 

paroxysmal  mental  disorders, 
236. 

permanent    mental    disorders, 
234. 

traumatic,  457. 

treatment  of,  243. 
Epileptic  absence,  236. 
Epileptic  automatism,  237. 
Epileptic  delirium,  237. 

diagnosis,  241. 

duration,  240. 

symptoms,  238. 

treatment,  245. 
Epileptic  dementia,  235. 
Epileptic  furor,  238. 
Ei:)ileptic  stupor,  237. 
Epileptic  vertigo,  236.  , 


INDEX  OF  SUBJECTS. 


515 


Epileptiform  seizures,  in  acute 
alcoholism,  3G6. 

in  brain  tumor,  492. 

in  cerebral  arteriosclerosis,  448. 

in  cerebral  syphilis,  438. 

in  delirium  tremens,  381. 

in  dementia  pra3cox,  251. 

in  general  paresis,  413. 
Eroticism,  296,  336,  342. 
Eruptive  fevers,  469. 
Erythrophobia,  352. 
]Stat  crible,  450. 
Ether,  477. 
Etiology,  1. 
Eugenics,  191,  200. 
Euphoria,  83,  241,  295,  391,  414, 

473,  479. 
Examination,  for  aphasia,  151. 

mental,  101. 

methods  of,  94. 

physical,  100. 
Excitement,  catatonic,  255,  277. 

maniacal,  293. 

of  general  paresis,  415. 

treatment  of,  161. 
Exhaustion  psychoses,  11,  462. 
Exliibitionism,  343,  500. 

Fabrications,  see  Pseudo-remi- 
niscences, also  Hallucina- 
tions of  memory. 

False  interpretations,  see  Delu- 
sional interpretations. 

Family  history,  95. 

Febrile  delirium,  11. 

Feeble-mindedness,  196,  228. 
and  crime,  215. 

Fetichism,  343. 

Field  workers,  95. 

Fixed  ideas,  63,  287,  308,  319, 
331,  336. 

Flight  of  ideas,  61,  294,  319,  465. 


Food,  refusal  of,  41,  169,  258, 
331,  386,  415,  470,  496. 

Forced  feeding,  170. 

Foreign-born  insane,  18,  209. 

Freedom  of  the  will,  x,  213. 

Frigidity,  336,  342. 

Fuchs-Rosenthal  counting  cham- 
ber, 113. 

Furor,  e[)ileptic,  238. 

General  paresis,  8,  13,  15,  115, 
224,  242,  274,  372,  381,  393, 
441,  451,  492,  504. 

course,  417. 

diagnosis,  419. 

essential  symptoms,  396 

etiology,  425. 

forms,  413. 

inconstant  symi)toms,  404. 

pathology,  421. 

prevention,  432. 

prodromata,  394. 

prognosis,  417. 

treatment,  433. 

treponema  'pallidum  in,  428. 
Genital  anomalies,  342. 
Germans,  insanity  in,  13. 
Germ-plasmic  determiners,  3. 
Goitre,  487,  489. 
Gothenburg  system,  202. 
Guilt,  214. 

Hcematoma  auris,  410. 
Hsemolytic  system,  116. 
Hallucinations,  24,  236,  238,  265, 
272,  279,  288,  300,  303,  308, 
329,  336,  348,  377,  385,  391, 
405,  458,  466,  480,  482,  496, 
503. 

auditory,  36. 

by  suggestion,  35. 

combined,  30,  377. 

conscious,  26. 


516 


INDEX  OF  SUBJECTS. 


Hallucinations,  definitions  of,  24. 

diagnosis  of,  31. 

etiology  of,  33. 

indifferent,  28. 

induced,  35. 

motor,  41,  272. 

motor  graphic,  43. 

motor  verbal,  42. 

of  general  sensibility,  41,  378. 

of  memory,  55,  389,  499. 

of  smell,  40. 

of  taste,  40. 

of  the  genital  sense,  41. 

of  touch,  41. 

peripheral,  34. 

pleasing,  28. 

preceding  sleep,  33. 

properties  of,  25. 

psychic,  65. 

reflex,  34. 

theories  of,  44. 

unilateral,  34,  46. 

unpleasant  or  painful,  28,  377. 

visual,  39,  378. 
Hallucinosis,  acute,  385. 
Handwriting,  106,  400. 
Harehp,  341. 

Head  injuries,  9,  10,  208,  430. 
Hebephrenia,  246. 
Hebrews,  insanity  in,  12,  13. 
Hemorrhage,  11. 

cerebral,  447. 
Heredity,  2,  95,   193,   199,  214, 
225,  280,  315,  324,  355,  360, 
373,  429,  489,  497. 

atavistic,  2,  360. 

collateral,  2. 

convergent,  360. 

direct,  2. 

dissimilar,  2. 

Mendelian  theory  of,  3. 

similar,  2. 


History,  family,  95. 

of  psychosis,  99. 

personal,  97. 
History  taking,  94. 
Homicide,  30,  349. 
Huntington's  chorea,  97,  359. 
Hydrotherapy,  163,  339. 
Hygiene,  mental,  193. 
Hyoscine,  167. 
Hyperconsciousness,  47,  50. 
Hyperrhnesia,  general,  57. 

partial,  58. 
Hypnal,  166. 
Hypnotism,  339,  355. 
Hysteria,  334. 

diagnosis,  337. 

episodic  mental  disorders,  336. 

permanent   mental   disorders, 
334. 

prognosis,  338. 

treatment,  339. 
Hysterical  lying,  336. 
Hysterical  mania,  337. 
Hysterical  melancholia,  337. 

Ideas,   autochthonous,    64,   272. 
fixed,  see  Fixed  ideas, 
guiding,  59. 
hypochondriacal,  68,  267,  271, 

300,  308,  329,  404,  496. 
imperative,  63,  308,  319,  331, 

347. 
melancholy,  67,  264,  266,  329, 

366,  404,  466,  482,  502. 
metaphysical,  69. 
of   culpability,    68,    266,    329, 

404. 
of  grandeur,  73,  241,  264,  267, 

272,  287,  299,  404,  466,  482, 

502. 
of  humility,  68,  266,  308,  329. 
of  immensity,  69. 


INDEX  OF  SUBJECTS. 


517 


Ideas,  of  immortality,  69. 

of    jealousy,    291,    369,    388, 

602. 
of  negation,  69,  267,  329,  502. 
of  persecution,   71,  264,  266, 
267,  271,  287,  300,  329,  366, 
369,  385,  404,  405,  466,  482, 
498,  502. 
of  possession,  93,  267. 
of  ruin,  68,  266,  329,  404,  502. 
of  self-accusation,  308,  502. 
subconscious,  64. 
Idiocy,  ix,  228,  490. 
Illegitimacy,  11. 
Illness  of  relatives,  11. 
Illusions,  23,  266,  271,  300,  308, 
329,  377,  385,  391,  405,  460, 
466,  480. 
Imbecility,  228,  490. 
Immigrants,  insane,  18. 

deportation  of,  209. 
Immigration,  18,  209. 
Immorality,  sexual,  216. 
Imperative  ideas,  63,  308,  319, 

331,  347. 
Impulse,  conscious,  88. 
of  passion,  87. 
simple,  87. 
Inanition,  469. 

Incoherence,  61,  249,  278,  465. 
Incompetence,  legal,  211. 
Increase  of  insanity,  185. 
Indifference,  74,  229,  249,  255, 
276,  318,  369,  391,  397,  466, 
475,  479,  485. 
Infectious  deliria,  458,  461. 
Influenza,  469. 

Insane,  foreign-born,  18,  209. 
native,  18. 
reasoning,  290. 
Insane  immigrants,  18. 
deportation  of,  209. 


Insanity,  x,  xi. 

alternating,  313. 

and  crime,  21^. 

circular,  314. 

is  it  on  the  increase?  185. 

manic-depressive,  14,  293. 

moral,  ix,  356. 

of  double  form,  313. 

periodic  or  recurrent,  312. 
Insight,  105. 

Intelligence  tests,  131,  151. 
Intoxications,  363,  368,  471,  477, 

479. 
Intracranial  medication,  433. 
Intraspinal  medication,  433. 
Inversion,  sexual,  346. 
Involutional     melanchoUa,     14, 
324. 

causes,  324. 

prodromal  period,  324. 

prognosis,  332. 

symptoms,  324. 

treatment,  333. 
Irish,  insanity  in,  12,  13. 
IrritabiHty,   76,    229,    234,   271, 
293,  296,  319,  361,  369,  397, 
459,  500. 
Isolation,  164,  339. 
Italians,  insanity  in,  13. 

Jealousy  delusion,  in  chronic  al- 
coholism, 369,  388. 
in  paranoia,  291. 

Jews,  insanity  in,  12,  13. 

Joy,  sec  Euphoria. 

Judgment,  26,  65,  294,  306,  339, 
357,  361,  369,  398,  499. 

Kent-Rosanoff  test,  155. 
Kidney  lesions,  373,  383,  448. 
Kleptomania,  349. 
Korsakoff's  disease,  388. 


518 


INDEX  OF  SUBJECTS. 


Lactation,  11. 

Lacunar  softenings,  see  Slit-like 

defects. 
Lange's  colloidal  gold  test,  128, 

419. 
Law  of  amnesia,  53. 
Legal  incompetence,  211. 
Lisping  speech,  229. 
Litigious  paranoiacs,  290. 
Local  option,  206. 
Logorrhea,  in  mania,  298. 

in  melancholia,  311. 
Love  affairs,  11. 
Lumbar  puncture,  110,  419. 
Lunacy,  xi,  160. 
Lying,  hysterical,  336. 
Lymphocytosis,  419. 
Lypemania,  see  MelanchoHa. 

Macrocephaly,  341. 

Make-up,  constitutional,  97,  279, 

284,  315. 
Mania,  293. 

chronic,  321. 

confused,  303. 

delusional,  298, 

recurrent,  312. 

simi)lo,  294. 
Manic-depressive  insanity,  7,  10, 
13,   14,  223,  242,  293,  338, 
419,  504. 

course,  304,  309. 

diagnosis,  223,  242,  316,  338, 
419,  504. 

etiology,  314. 

homogeneity  of,  316. 

progTiosis,  304,  309,  314. 

treatment,  305,  310,  321. 

t>T>cs  of,  293. 
Marital  condition,  16. 
Marriage  restriction,  199 
Masochism,  345. 


Masturbation,  343. 

Measuring  scale  of  intelligence, 

131. 
Mechanical  restraint,  162. 
Medication,  in  excitement,  164. 

intracranial,  433. 

intraspinal,  433. 
Medico-legal  questions,  210. 
MelanchoHa,  agitated,  324,  328. 

anxious,  324,  328. 

delusional,  329. 

stuporous,  324,  329. 
Melancholia,    involutional,     14, 
324. 

causes,  324. 

prodromal  period,  324. 

prognosis,  332. 

symptoms,  324. 

treatment,  333. 
Melancholic  wasting,  332. 
Memory,  51,  228,  248,  335,  389, 
396. 

disorders  of,  51. 

exaltation  of,  57. 

illusions  and  hallucinations  of, 
55,  389,  499. 
Mendelian  theory  of  heredity,  3. 
Menstruation,  327. 
Mental  ability,   point  scale  for 

measuring,  151. 
Mental  ahenation,  x. 
Mental  automatism,   nee   Auto- 
matism, mental. 
Mental  confusion,  60,  325,  462. 

delirious  form,  465. 

hjTKTacute  form,  467. 

simple  form,  464. 

stuporous  form,  466. 
Mental  thseases,  ix. 
Mental  examhiation,  101. 
Mental  hygiene,  193. 
Metaphysical  ideas,  69. 


INDEX  OF  SUBJECTS. 


519 


"Metasyphilitic"  disorders,  426. 
Microcephaly,  341. 
Migraine,  96. 
Mistakes  of  identity,  24,  272, 300, 

329,  391. 
Monomania,  see  Paranoia. 
Moral  insanity,  ix,  356. 
Morbid  religious  fanaticism,  234. 
Morphinomania,  471. 

causes,  471. 

evolution,  473. 

symptoms    of    abstinence    in, 
476. 

treatment,  477. 
Multiple  sclerosis,  492. 
Mutism,  43,  89,   101,  258,  307. 
Mystics,  291. 
Myxoedema,  485. 

Native  insane,  18. 
Necrophilia,  345. 
Negativism,  88,  258,  277,  398. 
Negroes,  insanity  in,  13. 
Neologisms,  38,  265. 
Neuroglia,  lesions  of,  in  general 

paresis,  423. 
Noguchi's  butyric  acid  test,  131, 

420. 
Nosophobia,  351. 
NuUiplex  inheritance,  4. 

Obsessions,  347,  358. 

homicidal,  349. 

impulsive,  349. 

inhibiting,  350. 

intellectual,  348. 

suicidal,  349. 
Occupation  delirium,  378. 
Occupation  dreams,  370. 
Occupation    in   the   etiology   of 

mental  disorders,  16,  431. 
Onanism,  see  Masturbation. 


Onomatomania,  349. 
Opium,  in  excitement,  164. 

in  epilepsy,  245. 

in    involutional    melancholia, 
333. 
Organic  cerebral  affections,  491. 
Orientation,  allopsychic,  47,  377. 

autopsy  chic,  47,  377. 

of  person,  47. 

of  place,  47. 

of  time,  47. 

Panophobia,  347,  352. 
Paraldehyde,  166. 
Paranoia,  287. 

originaire,  273,  288. 

guerulens,  290. 
Paranoid  dementia,  265. 
"Parasyphilitic"  disorders,  426. 
Parole  of  patients,  179. 
Paroxysmal    mental    puerilism, 

92. 
Pathological  drunkenness,  363. 
Pathological    suggestibility,    86, 
229,  250,  258,  277,  336,  501. 
Pellagra  in   relation   to  central 

neuritis,  495. 
Perception,  disorders  of,  21. 

imaginary,  24. 

inaccurate,  23. 

insufficiency  of,  22,  318,  462. 
Perivascular  gliosis,  447. 
Personal  history,  97. 
Personality,  disorders  of,  90. 

reduplication  of,  90. 

transformation  of,  90. 
Phobias,  351. 
Phonemes,  36,  276. 
Physical  examination,  100. 
Plasma  cells,  423. 
Point  scale  for  measuring  men- 
tal ability,  151. 


520 


INDEX  OF  SUBJECTS. 


Polyneuritic  psychosis,  388. 

course,  391. 

diagnosis,  392. 

etiology,  388. 

prognosis,  391. 

symptoms,  389. 

treatment,  392. 
Post-epileptic  stupor,  237. 
Pregnancy,  10. 

Presenile  paranoid  state,  502.  . 
Pressure  sores,  411,  434. 
Prevalence  of  mental  disorders, 

185. 
Prevention  of  insanity,  191. 
Primary   mental    confusion,    see 

Mental  confusion. 
Prognosis,  183. 
Prohibition,  205. 
Prostitution,  195. 

and  mental  defects,  196. 

control  of,  198. 
Pseudo-reminiscences,    56,    229, 

299,  335,  389,  499. 
Psychic  causes,  10. 
Psychic  pain,  76,  306,  324,  415, 

502. 
Psycho-analysis,  176. 
Psychopathic  wards  in   general 

hospitals,  210. 
Psychopaths,  constitutional,  339. 
Psychoses,  ix. 
Psychotherapy,    173,    286,    292, 

310,  339,  355. 
Puberty,  281. 
Puerperal  state,  469. 
Punishment,  213. 
Pui)illary  disorders  in  dementia 
pra^cox,  252. 

in  general  paresis,  401. 
Pyromania,  349. 

Race,  12. 


Raptus  melancholictis,  329. 
Reactions,  29,  80,  82,  85,  249, 
256,  266,  288,  293,  297,  306, 
319,  330,  336,  361,  398,  475, 
481,  500. 
automatic,  85,  238,  336. 
voluntary,  85,  336. 
Reading  test,  105. 
Recessive  characters,  3,  360. 
Recurrency  of  insanity,  180,  184, 

275,  293,  339,  387,  479. 
Refusal  of  food,  41,  169,  258,  331, 

386,  415,  470,  496. 
Religious  scruples,  351. 
Remissions  in  dementia  prsecox, 
275. 
in  general  paresis,  418. 
Respiratory  changes    in    anger, 
82. 
in  depression,  78. 
in  euphoria  or  joy,  84. 
Responsibility,  x. 
criminal,  213. 
legal  conception  of,  213. 
Rest  in  bed,  162,  305,  310,  333, 

384,  392,  469. 
Restraint,  162. 
Reticence,  31. 

Retrospective   falsifications,   66. 
Ross- Jones  test,  131,  420. 
Rural  environment,  15,  432. 

Sadism,  344. 
Hicnium  prajcox,  498. 
Scanning  sjjcech,  400. 
Scaphocephaly,  341. 
Scarlet  fever,  280. 
Scruples,  351. 
Segregation,  199. 
Sejunction,  46. 
Self-mutilation,  169. 
Senile  delirium,  503. 


INDEX  OF  SUBJECTS. 


521 


Senile  dementia,  14,  54,  372,  419, 
451,  497. 
course,  503. 
diagnosis,  504. 
etiology,  497. 
prognosis,  503. 
symptoms,  498. 
treatment,  504. 
Sex  in  the  etiology  of  insanity, 

14,  431. 
Sexual  inversion,  346. 
Sexual  perversion,  342. 
"Shut  in"  make-up,  279,  284. 
Simplex  inheritance,  4. 
Sitiophobia,  see  Refusal  of  food. 
Slit-Uke  defects  in  cerebral  ar- 

terioclerosis,  449. 
Social  factors  in  the  causation  of 

alcoholism,  373. 
Softening  of  the  brain,  447. 
Somnal,  166. 

Speech  disturbances  in  general 
paresis,  399. 
in  idiocy  and  imbecility,  229. 
Spinal    cord   lesions   in   general 

paresis,  423. 
Stammering,  229. 
States  of  obscuration,  49,  337. 
Statistical  data  form,  108. 
Stealing  of  thoughts,  38. 
Stereotypy,  88,  256,  258,  278. 
Sterilization,  199. 
Stupor,   in   involutional   melan- 
cholia, 324,  329. 
in  catatonia,  257,  277. 
in  manic-depressive  insanity, 

309,  311. 
in  primary  mental  confusion, 

466. 
post-epileptic,  237. 
Stuttering,  229. 
Subconscious  idea,  64,  335. 


Suggestibility,    see   Pathological 

suggestibility. 
Suggestion,  35,   173,   286,    310, 

339,  355,  374,  380,  390. 
Suicide,  70,  80,  96,  167,  238,  264, 

310,  328,  332,  333,  349,  366, 

386,  415,  468,  496,  502. 
Sulphonal,  165. 
Symptoms  of  abstinence  in  mor- 

phinomania,  476. 
Syndrome  of   Cotard,   69,    267, 

329. 
Syphilis,  8,  15,  98,  109,  115,  128, 

195,  206,  224,  227,  425,  432, 

437,  444. 
Systematized  delusions,  67,  265, 

272,  278,  287,  308,  386,  405, 

483,  502. 

Tabes,  420. 

Tabetic  form  of  general  paresis, 

416. 
Tattooing,  342. 
Testamentary  capacity,  211. 
Tetronal,  165. 
Thyrogenic  psychoses,  485. 
Thyroid  gland,  486. 
Thyroid  medication,  487. 
Traumatic  disorders,  453. 

delirium,  455. 

dementia,  457. 

epilepsy,  457. 

neurasthenia,  455. 
Traumatism,  9, 10,  208,  430,  453. 
Treatment,  of  insanity,  159. 

of  excitement,  161. 

of  refusal  of  food,  169. 

of  suicidal  tendency,  169. 
Tremors,  82,  100,  371,  379,  399, 

451,  476,  501. 
Treponema  pallidum,  427,  428. 
Trional,  165. 


522 


INDEX  OF  SUBJECTS. 


Tube-feeding,  170. 
Tuberculosis,  276,  332,  392,  412, 

424,  468,  477. 
Tumor  of  the  brain,  491. 
Typhoid  fever,  280,  461,  469. 
Typhus  fever,  461. 

Unbalanced  persons,  340. 
Unconsciousness,  47. 
Ursemic  delirium,  482. 
Urban  environment,  15,  432. 

Vagabonds,  341. 
Variola,  461. 
Verbigeration,  88,  256. 


Visions,  see  Hallucinations,  vis- 
ual. 

Wassermann  reaction,  115,  419. 

collecting  specimens,  124. 

principle,  115. 

reagents,  118. 

technique,  126. 
Wasting  in  melancholia,  332. 
Wet  packs,  163. 
Writing  test,  105,  298,  307,  400. 

Yerkes-Bridges  tests,  151. 

Zoopsia,  370. 


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